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NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameNEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN
Plan identification number 501

NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

NEW VISTA HEALTH SERVICES, LLC has sponsored the creation of one or more 401k plans.

Company Name:NEW VISTA HEALTH SERVICES, LLC
Employer identification number (EIN):461622036
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about NEW VISTA HEALTH SERVICES, LLC

Jurisdiction of Incorporation: California Secretary of State
Incorporation Date: 2012-12-18
Company Identification Number: 201235410082
Legal Registered Office Address: 8349 FOOTHILL BLVD STE B

SUNLAND
United States of America (USA)
91040

More information about NEW VISTA HEALTH SERVICES, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-11-01
5012020-11-01
5012019-11-01
5012018-11-01
5012017-11-01
5012016-11-01JOEL WALDMAN
5012015-11-01JOEL WALDMAN

Plan Statistics for NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN

Measure Date Value
2021: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-11-01133
Total number of active participants reported on line 7a of the Form 55002021-11-01127
Number of retired or separated participants receiving benefits2021-11-013
Number of other retired or separated participants entitled to future benefits2021-11-010
Total of all active and inactive participants2021-11-01130
2020: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-11-01122
Total number of active participants reported on line 7a of the Form 55002020-11-01131
Number of retired or separated participants receiving benefits2020-11-012
Number of other retired or separated participants entitled to future benefits2020-11-010
Total of all active and inactive participants2020-11-01133
2019: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-11-01125
Total number of active participants reported on line 7a of the Form 55002019-11-01119
Number of retired or separated participants receiving benefits2019-11-013
Number of other retired or separated participants entitled to future benefits2019-11-010
Total of all active and inactive participants2019-11-01122
2018: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-11-01187
Total number of active participants reported on line 7a of the Form 55002018-11-01125
Number of retired or separated participants receiving benefits2018-11-010
Number of other retired or separated participants entitled to future benefits2018-11-010
Total of all active and inactive participants2018-11-01125
2017: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-11-01142
Total number of active participants reported on line 7a of the Form 55002017-11-01179
Number of retired or separated participants receiving benefits2017-11-018
Number of other retired or separated participants entitled to future benefits2017-11-010
Total of all active and inactive participants2017-11-01187
2016: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-11-01170
Total number of active participants reported on line 7a of the Form 55002016-11-01142
Number of retired or separated participants receiving benefits2016-11-010
Number of other retired or separated participants entitled to future benefits2016-11-010
Total of all active and inactive participants2016-11-01142
2015: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-11-01130
Total number of active participants reported on line 7a of the Form 55002015-11-01169
Number of retired or separated participants receiving benefits2015-11-011
Number of other retired or separated participants entitled to future benefits2015-11-010
Total of all active and inactive participants2015-11-01170

Form 5500 Responses for NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN

2021: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-11-01Type of plan entitySingle employer plan
2021-11-01Submission has been amendedNo
2021-11-01This submission is the final filingNo
2021-11-01This return/report is a short plan year return/report (less than 12 months)No
2021-11-01Plan is a collectively bargained planNo
2021-11-01Plan funding arrangement – General assets of the sponsorYes
2021-11-01Plan benefit arrangement – InsuranceYes
2020: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-11-01Type of plan entitySingle employer plan
2020-11-01Submission has been amendedNo
2020-11-01This submission is the final filingNo
2020-11-01This return/report is a short plan year return/report (less than 12 months)No
2020-11-01Plan is a collectively bargained planNo
2020-11-01Plan funding arrangement – General assets of the sponsorYes
2020-11-01Plan benefit arrangement – InsuranceYes
2019: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-11-01Type of plan entitySingle employer plan
2019-11-01Submission has been amendedNo
2019-11-01This submission is the final filingNo
2019-11-01This return/report is a short plan year return/report (less than 12 months)No
2019-11-01Plan is a collectively bargained planNo
2019-11-01Plan funding arrangement – General assets of the sponsorYes
2019-11-01Plan benefit arrangement – InsuranceYes
2018: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-11-01Type of plan entitySingle employer plan
2018-11-01Submission has been amendedNo
2018-11-01This submission is the final filingNo
2018-11-01This return/report is a short plan year return/report (less than 12 months)No
2018-11-01Plan is a collectively bargained planNo
2018-11-01Plan funding arrangement – General assets of the sponsorYes
2018-11-01Plan benefit arrangement – InsuranceYes
2017: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-11-01Type of plan entitySingle employer plan
2017-11-01Submission has been amendedNo
2017-11-01This submission is the final filingNo
2017-11-01This return/report is a short plan year return/report (less than 12 months)No
2017-11-01Plan is a collectively bargained planNo
2017-11-01Plan funding arrangement – General assets of the sponsorYes
2017-11-01Plan benefit arrangement – InsuranceYes
2016: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-11-01Type of plan entitySingle employer plan
2016-11-01Submission has been amendedNo
2016-11-01This submission is the final filingNo
2016-11-01This return/report is a short plan year return/report (less than 12 months)No
2016-11-01Plan is a collectively bargained planNo
2016-11-01Plan funding arrangement – General assets of the sponsorYes
2016-11-01Plan benefit arrangement – InsuranceYes
2015: NEW VISTA HEALTH SERVICES, LLC HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-11-01Type of plan entitySingle employer plan
2015-11-01Submission has been amendedNo
2015-11-01This submission is the final filingNo
2015-11-01This return/report is a short plan year return/report (less than 12 months)No
2015-11-01Plan is a collectively bargained planNo
2015-11-01Plan funding arrangement – General assets of the sponsorYes
2015-11-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number920027
Policy instance 4
Insurance contract or identification number920027
Number of Individuals Covered127
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $14,386
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $100,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,386
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberG0763-N7716
Policy instance 3
Insurance contract or identification numberG0763-N7716
Number of Individuals Covered68
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $23,392
Total amount of fees paid to insurance companyUSD $8,660
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $471,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,392
Amount paid for insurance broker fees8660
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232174
Policy instance 2
Insurance contract or identification number232174
Number of Individuals Covered66
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $19,603
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $455,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,603
Insurance broker organization code?3
PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )
Policy contract number18662
Policy instance 1
Insurance contract or identification number18662
Number of Individuals Covered114
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $8,858
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $69,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,858
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0912725
Policy instance 1
Insurance contract or identification number0912725
Number of Individuals Covered67
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $25,719
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $428,653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,719
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232174
Policy instance 2
Insurance contract or identification number232174
Number of Individuals Covered59
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $21,527
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $460,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,527
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number920027
Policy instance 3
Insurance contract or identification number920027
Number of Individuals Covered131
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $18,043
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $150,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,043
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number920027
Policy instance 3
Insurance contract or identification number920027
Number of Individuals Covered119
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $20,431
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $171,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,431
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0912725
Policy instance 2
Insurance contract or identification number0912725
Number of Individuals Covered73
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $27,925
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $465,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,925
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232174
Policy instance 1
Insurance contract or identification number232174
Number of Individuals Covered56
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $21,996
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $406,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,996
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number920027
Policy instance 2
Insurance contract or identification number920027
Number of Individuals Covered125
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $24,290
Total amount of fees paid to insurance companyUSD $2,354
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $179,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,515
Amount paid for insurance broker fees2354
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0912725
Policy instance 3
Insurance contract or identification number0912725
Number of Individuals Covered70
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $25,920
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $427,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,920
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232174
Policy instance 1
Insurance contract or identification number232174
Number of Individuals Covered61
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $20,834
Total amount of fees paid to insurance companyUSD $220
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $420,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,834
Insurance broker organization code?3
Amount paid for insurance broker fees220
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0AK2M
Policy instance 8
Insurance contract or identification numberGUC0AK2M
Number of Individuals Covered29
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $1,869
Total amount of fees paid to insurance companyUSD $1,227
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,462
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 number9828427
Policy instance 7
Insurance contract or identification number9828427
Number of Individuals Covered143
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $1,354
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,330
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 number232174
Policy instance 1
Insurance contract or identification number232174
Number of Individuals Covered68
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $22,559
Total amount of fees paid to insurance companyUSD $717
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $449,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0AK2M
Policy instance 2
Insurance contract or identification numberGUDH0AK2M
Number of Individuals Covered17
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $780
Total amount of fees paid to insurance companyUSD $590
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AK2M
Policy instance 3
Insurance contract or identification numberGVTL0AK2M
Number of Individuals Covered53
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $2,821
Total amount of fees paid to insurance companyUSD $1,252
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00543359
Policy instance 4
Insurance contract or identification number00543359
Number of Individuals Covered179
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $7,989
Total amount of fees paid to insurance companyUSD $799
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $79,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR0AK2M
Policy instance 5
Insurance contract or identification numberGUPR0AK2M
Number of Individuals Covered19
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $899
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,101
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0AK2M
Policy instance 6
Insurance contract or identification numberGUDE0AK2M
Number of Individuals Covered8
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $200
Total amount of fees paid to insurance companyUSD $341
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )
Policy contract number13644
Policy instance 6
Insurance contract or identification number13644
Number of Individuals Covered119
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $91,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,548
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number278816
Policy instance 5
Insurance contract or identification number278816
Number of Individuals Covered109
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $208
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232174
Policy instance 4
Insurance contract or identification number232174
Number of Individuals Covered85
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $598,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,172
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AK2M
Policy instance 3
Insurance contract or identification numberG000AK2M
Number of Individuals Covered68
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $70,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,545
Amount paid for insurance broker fees1999
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number278816
Policy instance 2
Insurance contract or identification number278816
Number of Individuals Covered81
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $32,788
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $642,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,788
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9828427
Policy instance 1
Insurance contract or identification number9828427
Number of Individuals Covered99
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,115
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC

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