DEL TACO LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan DEL TACO LLC WELFARE BENEFIT PLAN
Measure | Date | Value |
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2022: DEL TACO LLC WELFARE BENEFIT PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 652 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 0 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 0 |
Number of employers contributing to the scheme | 2022-01-01 | 0 |
2021: DEL TACO LLC WELFARE BENEFIT PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-01-01 | 643 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 652 |
Number of retired or separated participants receiving benefits | 2021-01-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
Total of all active and inactive participants | 2021-01-01 | 653 |
Number of employers contributing to the scheme | 2021-01-01 | 0 |
2020: DEL TACO LLC WELFARE BENEFIT PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 754 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 643 |
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 | 0 |
Total of all active and inactive participants | 2020-01-01 | 643 |
Number of employers contributing to the scheme | 2020-01-01 | 0 |
2019: DEL TACO LLC WELFARE BENEFIT PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-01-01 | 797 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 748 |
Number of retired or separated participants receiving benefits | 2019-01-01 | 6 |
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 | 754 |
Number of employers contributing to the scheme | 2019-01-01 | 0 |
2018: DEL TACO LLC WELFARE BENEFIT PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-01-01 | 619 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 794 |
Number of retired or separated participants receiving benefits | 2018-01-01 | 3 |
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 | 797 |
Number of employers contributing to the scheme | 2018-01-01 | 0 |
2017: DEL TACO LLC WELFARE BENEFIT PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-01-01 | 585 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 619 |
Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
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 | 619 |
2016: DEL TACO LLC WELFARE BENEFIT PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-01-01 | 533 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 585 |
Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
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 | 585 |
2015: DEL TACO LLC WELFARE BENEFIT PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-01-01 | 526 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 533 |
Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
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 | 533 |
2014: DEL TACO LLC WELFARE BENEFIT PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-01-01 | 545 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 526 |
Number of retired or separated participants receiving benefits | 2014-01-01 | 3 |
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 | 529 |
2013: DEL TACO LLC WELFARE BENEFIT PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-05-01 | 505 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 528 |
Number of retired or separated participants receiving benefits | 2013-05-01 | 17 |
Number of other retired or separated participants entitled to future benefits | 2013-05-01 | 0 |
Total of all active and inactive participants | 2013-05-01 | 545 |
2012: DEL TACO LLC WELFARE BENEFIT PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-05-01 | 500 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 489 |
Number of retired or separated participants receiving benefits | 2012-05-01 | 4 |
Number of other retired or separated participants entitled to future benefits | 2012-05-01 | 12 |
Total of all active and inactive participants | 2012-05-01 | 505 |
2011: DEL TACO LLC WELFARE BENEFIT PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-05-01 | 499 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-05-01 | 500 |
Number of retired or separated participants receiving benefits | 2011-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2011-05-01 | 0 |
Total of all active and inactive participants | 2011-05-01 | 500 |
2009: DEL TACO LLC WELFARE BENEFIT PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-05-01 | 387 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-05-01 | 387 |
Number of retired or separated participants receiving benefits | 2009-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2009-05-01 | 0 |
Total of all active and inactive participants | 2009-05-01 | 387 |
2022: DEL TACO LLC WELFARE BENEFIT PLAN 2022 form 5500 responses |
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2022-01-01 | Type of plan entity | Single employer plan |
2022-01-01 | This submission is the final filing | Yes |
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: DEL TACO LLC WELFARE BENEFIT PLAN 2021 form 5500 responses |
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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: DEL TACO LLC WELFARE BENEFIT PLAN 2020 form 5500 responses |
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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: DEL TACO LLC WELFARE BENEFIT PLAN 2019 form 5500 responses |
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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: DEL TACO LLC WELFARE BENEFIT PLAN 2018 form 5500 responses |
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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: DEL TACO LLC WELFARE BENEFIT PLAN 2017 form 5500 responses |
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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: DEL TACO LLC WELFARE BENEFIT PLAN 2016 form 5500 responses |
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2016-01-01 | Type of plan entity | Single employer plan |
2016-01-01 | Submission has been amended | No |
2016-01-01 | This submission is the final filing | No |
2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-01-01 | Plan is a collectively bargained plan | No |
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: DEL TACO LLC WELFARE BENEFIT PLAN 2015 form 5500 responses |
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2015-01-01 | Type of plan entity | Single employer plan |
2015-01-01 | Submission has been amended | No |
2015-01-01 | This submission is the final filing | No |
2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-01-01 | Plan is a collectively bargained plan | No |
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: DEL TACO LLC WELFARE BENEFIT PLAN 2014 form 5500 responses |
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2014-01-01 | Type of plan entity | Single employer plan |
2014-01-01 | Submission has been amended | No |
2014-01-01 | This submission is the final filing | No |
2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-01-01 | Plan is a collectively bargained plan | No |
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: DEL TACO LLC WELFARE BENEFIT PLAN 2013 form 5500 responses |
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2013-05-01 | Type of plan entity | Single employer plan |
2013-05-01 | Submission has been amended | No |
2013-05-01 | This submission is the final filing | No |
2013-05-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2013-05-01 | Plan is a collectively bargained plan | No |
2013-05-01 | Plan funding arrangement – Insurance | Yes |
2013-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2013-05-01 | Plan benefit arrangement – Insurance | Yes |
2013-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2012: DEL TACO LLC WELFARE BENEFIT PLAN 2012 form 5500 responses |
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2012-05-01 | Type of plan entity | Single employer plan |
2012-05-01 | Submission has been amended | No |
2012-05-01 | This submission is the final filing | No |
2012-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-05-01 | Plan is a collectively bargained plan | No |
2012-05-01 | Plan funding arrangement – Insurance | Yes |
2012-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2012-05-01 | Plan benefit arrangement – Insurance | Yes |
2012-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2011: DEL TACO LLC WELFARE BENEFIT PLAN 2011 form 5500 responses |
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2011-05-01 | Type of plan entity | Single employer plan |
2011-05-01 | Submission has been amended | No |
2011-05-01 | This submission is the final filing | No |
2011-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-05-01 | Plan is a collectively bargained plan | No |
2011-05-01 | Plan funding arrangement – Insurance | Yes |
2011-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2011-05-01 | Plan benefit arrangement – Insurance | Yes |
2011-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2009: DEL TACO LLC WELFARE BENEFIT PLAN 2009 form 5500 responses |
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2009-05-01 | Type of plan entity | Single employer plan |
2009-05-01 | Submission has been amended | No |
2009-05-01 | This submission is the final filing | No |
2009-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2009-05-01 | Plan is a collectively bargained plan | No |
2009-05-01 | Plan funding arrangement – Insurance | Yes |
2009-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2009-05-01 | Plan benefit arrangement – Insurance | Yes |
2009-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34 |
Policy instance | 4 |
Insurance contract or identification number | AHC34 | Number of Individuals Covered | 37 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $2,802 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $24,756 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,071 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC43 |
Policy instance | 3 |
Insurance contract or identification number | AHC43 | Number of Individuals Covered | 13 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $1,198 | Total amount of fees paid to insurance company | USD $21 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $11,627 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $500 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | FEES |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 869054G |
Policy instance | 2 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 650 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $26,162 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $374,820 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,081 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
Policy contract number | W0067306 |
Policy instance | 1 |
Insurance contract or identification number | W0067306 | Number of Individuals Covered | 658 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $5,298 | Total amount of fees paid to insurance company | USD $174,583 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $5,036,332 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,649 | Amount paid for insurance broker fees | 87365 | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES, NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
Policy contract number | W0067306 |
Policy instance | 1 |
Insurance contract or identification number | W0067306 | Number of Individuals Covered | 729 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $5,698 | Total amount of fees paid to insurance company | USD $173,090 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $5,046,969 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,849 | Amount paid for insurance broker fees | 86545 | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 869054G |
Policy instance | 2 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 652 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $20,059 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $316,977 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,030 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC43 |
Policy instance | 3 |
Insurance contract or identification number | AHC43 | Number of Individuals Covered | 17 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $1,550 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $13,769 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $544 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34 |
Policy instance | 4 |
Insurance contract or identification number | AHC34 | Number of Individuals Covered | 43 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $3,550 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $28,329 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,189 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34 |
Policy instance | 4 |
Insurance contract or identification number | AHC34 | Number of Individuals Covered | 43 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $3,369 | Total amount of fees paid to insurance company | USD $64 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $29,776 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,408 | Amount paid for insurance broker fees | 46 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
|
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC43 |
Policy instance | 3 |
Insurance contract or identification number | AHC43 | Number of Individuals Covered | 19 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $1,504 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $15,487 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $615 | 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 | 869054G |
Policy instance | 2 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 653 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $20,852 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $330,490 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,426 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 0 |
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CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
Policy contract number | W0067306 |
Policy instance | 1 |
Insurance contract or identification number | W0067306 | Number of Individuals Covered | 754 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $22,138 | Total amount of fees paid to insurance company | USD $158,086 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $4,516,989 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,069 | Amount paid for insurance broker fees | 79043 | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES | Insurance broker organization code? | 3 |
|
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
Policy contract number | W0067306 |
Policy instance | 1 |
Insurance contract or identification number | W0067306 | Number of Individuals Covered | 748 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $21,504 | Total amount of fees paid to insurance company | USD $136,120 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $4,010,369 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,752 | Amount paid for insurance broker fees | 68149 | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
|
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 869054G |
Policy instance | 2 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 669 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $21,919 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $274,241 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,960 | Insurance broker organization code? | 3 |
|
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC43 |
Policy instance | 3 |
Insurance contract or identification number | AHC43 | Number of Individuals Covered | 23 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,660 | Total amount of fees paid to insurance company | USD $16 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $17,323 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $674 | Amount paid for insurance broker fees | 14 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34 |
Policy instance | 4 |
Insurance contract or identification number | AHC34 | Number of Individuals Covered | 49 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $4,125 | Total amount of fees paid to insurance company | USD $157 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $28,492 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,949 | Amount paid for insurance broker fees | 124 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | C19260 |
Policy instance | 1 |
Insurance contract or identification number | C19260 | Number of Individuals Covered | 794 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $161,429 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $5,658,278 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $80,715 | 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 | 869054G |
Policy instance | 2 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 611 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $18,844 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $280,911 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,422 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC43 |
Policy instance | 3 |
Insurance contract or identification number | AHC43 | Number of Individuals Covered | 27 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $2,960 | Total amount of fees paid to insurance company | USD $16 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $19,945 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,010 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | FEES |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34 |
Policy instance | 4 |
Insurance contract or identification number | AHC34 | Number of Individuals Covered | 51 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $4,287 | Total amount of fees paid to insurance company | USD $110 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $27,583 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,868 | Amount paid for insurance broker fees | 78 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC43 |
Policy instance | 3 |
Insurance contract or identification number | AHC43 | Number of Individuals Covered | 27 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $1,964 | Total amount of fees paid to insurance company | USD $146 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $18,627 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $781 | Amount paid for insurance broker fees | 104 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | CVS INSURANCE SERVICES, INC. |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34 |
Policy instance | 4 |
Insurance contract or identification number | AHC34 | Number of Individuals Covered | 48 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $3,746 | Total amount of fees paid to insurance company | USD $91 | Other welfare benefits provided | VOLUNTARY BENEFITS | Welfare Benefit Premiums Paid to Carrier | USD $26,324 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,748 | Amount paid for insurance broker fees | 65 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | MONA MARCOS AND VARIOUS AGENTS |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 869054G |
Policy instance | 2 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 619 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $11,698 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $187,022 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,849 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | GARY A. PSOTKA |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | C19260 |
Policy instance | 1 |
Insurance contract or identification number | C19260 | Number of Individuals Covered | 840 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $200,369 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $4,783,564 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $100,185 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | GARY PSOTKA |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | C19260 |
Policy instance | 1 |
Insurance contract or identification number | C19260 | Number of Individuals Covered | 950 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $175,160 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $4,955,783 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $87,580 | Insurance broker organization code? | 3 | Insurance broker name | |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34/AHC43 |
Policy instance | 5 |
Insurance contract or identification number | AHC34/AHC43 | Number of Individuals Covered | 44 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $11,990 | Total amount of fees paid to insurance company | USD $262 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY BENEFITS | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $52,036 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,917 | Amount paid for insurance broker fees | 126 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | DAVID J. LASTER |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 898103-001 |
Policy instance | 2 |
Insurance contract or identification number | 898103-001 | Number of Individuals Covered | 502 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $23,378 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $234,671 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $11,689 | Insurance broker organization code? | 3 | Insurance broker name | VP BENEFITSGROUP |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 869054G |
Policy instance | 4 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 533 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $13,342 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $196,710 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,671 | Insurance broker organization code? | 3 | Insurance broker name | VP BENEFITSGROUP |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 898103-000 |
Policy instance | 3 |
Insurance contract or identification number | 898103-000 | Number of Individuals Covered | 468 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $5,890 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $58,717 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $2,945 | Insurance broker organization code? | 3 | Insurance broker name | VP BENEFITSGROUP |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 869054G |
Policy instance | 2 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 526 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $11,095 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $169,008 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,179 | Insurance broker organization code? | 3 | Insurance broker name | GARY PSOTKA |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 898103-001 |
Policy instance | 4 |
Insurance contract or identification number | 898103-001 | Number of Individuals Covered | 468 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $22,409 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $223,556 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $12,697 | Insurance broker organization code? | 3 | Insurance broker name | ROBERTO VELAZQUEZ |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 898103-000 |
Policy instance | 5 |
Insurance contract or identification number | 898103-000 | Number of Individuals Covered | 529 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $6,245 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $62,583 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $3,653 | Insurance broker organization code? | 3 | Insurance broker name | ROBERTO VALAZQUEZ |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34/AHC43 |
Policy instance | 3 |
Insurance contract or identification number | AHC34/AHC43 | Number of Individuals Covered | 26 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $7,441 | Total amount of fees paid to insurance company | USD $182 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY BENEFITS | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $42,145 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,278 | Amount paid for insurance broker fees | 15 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | ADAM H. MICHAELS |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | C19260 |
Policy instance | 1 |
Insurance contract or identification number | C19260 | Number of Individuals Covered | 967 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $162,413 | Total amount of fees paid to insurance company | USD $2,654 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $4,630,212 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $108,533 | Amount paid for insurance broker fees | 2654 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | FLYNN AND PIEL INS. SERVICES, LLC |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34/AHC43 |
Policy instance | 5 |
Insurance contract or identification number | AHC34/AHC43 | Number of Individuals Covered | 61 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $4,277 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY BENEFITS | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $29,969 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,277 | Insurance broker organization code? | 3 | Insurance broker name | CHRISTINE SEKAS AND VARIOUS AGENTS |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 869054G |
Policy instance | 4 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 528 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $7,806 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $110,574 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,806 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 898103-001 |
Policy instance | 6 |
Insurance contract or identification number | 898103-001 | Number of Individuals Covered | 324 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $7,735 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $93,184 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $7,735 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 ) |
Policy contract number | 60000977 |
Policy instance | 3 |
Insurance contract or identification number | 60000977 | Number of Individuals Covered | 69 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $10,253 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $172,897 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $10,253 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 528943 |
Policy instance | 8 |
Insurance contract or identification number | 528943 | Number of Individuals Covered | 89 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $7,620 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $131,244 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,620 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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HOMETOWN HEALTH (National Association of Insurance Commissioners NAIC id number: 48305 ) |
Policy contract number | 2350P |
Policy instance | 2 |
Insurance contract or identification number | 2350P | Number of Individuals Covered | 8 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $3,423 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $77,920 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,423 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 898103-000 |
Policy instance | 7 |
Insurance contract or identification number | 898103-000 | Number of Individuals Covered | 559 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $3,583 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $42,091 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $3,583 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | C19260 |
Policy instance | 1 |
Insurance contract or identification number | C19260 | Number of Individuals Covered | 852 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $87,050 | Total amount of fees paid to insurance company | USD $851 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,386,936 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $87,050 | Amount paid for insurance broker fees | 851 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 898103-000 |
Policy instance | 7 |
Insurance contract or identification number | 898103-000 | Number of Individuals Covered | 622 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $7,543 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $69,252 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $4,821 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 898103-001 |
Policy instance | 6 |
Insurance contract or identification number | 898103-001 | Number of Individuals Covered | 343 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $16,514 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $149,774 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $10,367 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34/AHC43 |
Policy instance | 5 |
Insurance contract or identification number | AHC34/AHC43 | Number of Individuals Covered | 50 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $8,005 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY BENEFITS | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $43,923 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,005 | Insurance broker organization code? | 3 | Insurance broker name | CHRISTINE SEKAS AND VARIOUS AGENTS |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 869054G |
Policy instance | 4 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 489 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $10,117 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $144,197 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,358 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 ) |
Policy contract number | 60000977 |
Policy instance | 3 |
Insurance contract or identification number | 60000977 | Number of Individuals Covered | 63 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $4,153 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $256,739 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $4,153 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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HOMETOWN HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95350 ) |
Policy contract number | 2350P |
Policy instance | 2 |
Insurance contract or identification number | 2350P | Number of Individuals Covered | 9 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 528943 |
Policy instance | 8 |
Insurance contract or identification number | 528943 | Number of Individuals Covered | 83 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $11,445 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $193,928 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,385 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | C19260 |
Policy instance | 1 |
Insurance contract or identification number | C19260 | Number of Individuals Covered | 895 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $160,562 | Total amount of fees paid to insurance company | USD $4,128 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | 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 EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $3,472,056 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $122,416 | Amount paid for insurance broker fees | 4128 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 528943 |
Policy instance | 3 |
Insurance contract or identification number | 528943 | Number of Individuals Covered | 68 | Insurance policy start date | 2011-05-01 | Insurance policy end date | 2012-04-30 | Total amount of commissions paid to insurance broker | USD $7,259 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $131,777 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | AHC34/AHC43 |
Policy instance | 6 |
Insurance contract or identification number | AHC34/AHC43 | Number of Individuals Covered | 53 | Insurance policy start date | 2011-05-01 | Insurance policy end date | 2012-04-30 | Total amount of commissions paid to insurance broker | USD $5,491 | Total amount of fees paid to insurance company | USD $377 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY BENEFITS | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $43,621 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 869054G |
Policy instance | 5 |
Insurance contract or identification number | 869054G | Number of Individuals Covered | 500 | Insurance policy start date | 2011-05-01 | Insurance policy end date | 2012-04-30 | Total amount of commissions paid to insurance broker | USD $10,856 | Total amount of fees paid to insurance company | USD $1,966 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $157,305 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 ) |
Policy contract number | 60000977 |
Policy instance | 4 |
Insurance contract or identification number | 60000977 | Number of Individuals Covered | 70 | Insurance policy start date | 2011-05-01 | Insurance policy end date | 2012-04-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $300,933 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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HOMETOWN HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95350 ) |
Policy contract number | 2350P |
Policy instance | 2 |
Insurance contract or identification number | 2350P | Number of Individuals Covered | 9 | Insurance policy start date | 2011-05-01 | Insurance policy end date | 2012-04-30 | Total amount of commissions paid to insurance broker | USD $6,564 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $109,447 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | C19260 |
Policy instance | 1 |
Insurance contract or identification number | C19260 | Number of Individuals Covered | 959 | Insurance policy start date | 2011-05-01 | Insurance policy end date | 2012-04-30 | Total amount of commissions paid to insurance broker | USD $150,848 | Total amount of fees paid to insurance company | USD $62 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | 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 EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $3,613,672 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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