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LUTHER BURBANK HEALTH PLAN 401k Plan overview

Plan NameLUTHER BURBANK HEALTH PLAN
Plan identification number 502

LUTHER BURBANK HEALTH PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

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

Company Name:LUTHER BURBANK CORPORATION
Employer identification number (EIN):680270948
NAIC Classification:522120
NAIC Description:Savings Institutions

Additional information about LUTHER BURBANK CORPORATION

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: C1518675

More information about LUTHER BURBANK CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LUTHER BURBANK HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022021-10-01
5022020-10-01
5022019-10-01
5022018-10-01
5022017-10-01
5022016-10-01SARA SLAUF SARA SLAUF2018-04-24
5022015-10-01SHANNON SCOTT
5022015-10-01SHANNON SCOTT
5022014-10-01NANCY HAUPENTHAL
5022013-10-01JEANIE MULHERN
5022012-10-01JEANIE MULHERN
5022011-10-01JEANIE MULHERN
5022010-10-01JEANIE MULHERN
5022009-10-01JEANIE MULHERN

Plan Statistics for LUTHER BURBANK HEALTH PLAN

401k plan membership statisitcs for LUTHER BURBANK HEALTH PLAN

Measure Date Value
2021: LUTHER BURBANK HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-01279
Total number of active participants reported on line 7a of the Form 55002021-10-01275
Number of retired or separated participants receiving benefits2021-10-013
Total of all active and inactive participants2021-10-01278
Total participants2021-10-01278
2020: LUTHER BURBANK HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year2020-10-01285
Total number of active participants reported on line 7a of the Form 55002020-10-01277
Number of retired or separated participants receiving benefits2020-10-014
Total of all active and inactive participants2020-10-01281
Total participants2020-10-01281
2019: LUTHER BURBANK HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year2019-10-01244
Total number of active participants reported on line 7a of the Form 55002019-10-01276
Number of retired or separated participants receiving benefits2019-10-016
Total of all active and inactive participants2019-10-01282
Total participants2019-10-01282
2018: LUTHER BURBANK HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year2018-10-01220
Total number of active participants reported on line 7a of the Form 55002018-10-01240
Number of retired or separated participants receiving benefits2018-10-015
Total of all active and inactive participants2018-10-01245
Total participants2018-10-01245
2017: LUTHER BURBANK HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year2017-10-01272
Total number of active participants reported on line 7a of the Form 55002017-10-01266
Number of retired or separated participants receiving benefits2017-10-017
Total of all active and inactive participants2017-10-01273
Total participants2017-10-01273
2016: LUTHER BURBANK HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01301
Total number of active participants reported on line 7a of the Form 55002016-10-01262
Number of retired or separated participants receiving benefits2016-10-0133
Total of all active and inactive participants2016-10-01295
Total participants2016-10-01295
2015: LUTHER BURBANK HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01377
Total number of active participants reported on line 7a of the Form 55002015-10-01285
Total of all active and inactive participants2015-10-01285
Total participants2015-10-01285
2014: LUTHER BURBANK HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year2014-10-01269
Total number of active participants reported on line 7a of the Form 55002014-10-01285
Total of all active and inactive participants2014-10-01285
Total participants2014-10-01285
2013: LUTHER BURBANK HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year2013-10-01196
Number of retired or separated participants receiving benefits2013-10-01269
Total of all active and inactive participants2013-10-01269
Total participants2013-10-01269
2012: LUTHER BURBANK HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year2012-10-01163
Total number of active participants reported on line 7a of the Form 55002012-10-01196
Total of all active and inactive participants2012-10-01196
Total participants2012-10-01196
2011: LUTHER BURBANK HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year2011-10-01159
Total number of active participants reported on line 7a of the Form 55002011-10-01163
Total of all active and inactive participants2011-10-01163
Total participants2011-10-01163
2010: LUTHER BURBANK HEALTH PLAN 2010 401k membership
Total participants, beginning-of-year2010-10-01138
Total number of active participants reported on line 7a of the Form 55002010-10-01159
Total of all active and inactive participants2010-10-01159
Total participants2010-10-01159
2009: LUTHER BURBANK HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year2009-10-01108
Total number of active participants reported on line 7a of the Form 55002009-10-01138
Total of all active and inactive participants2009-10-01138
Total participants2009-10-01138

Form 5500 Responses for LUTHER BURBANK HEALTH PLAN

2021: LUTHER BURBANK HEALTH PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Submission has been amendedNo
2021-10-01This submission is the final filingNo
2021-10-01This return/report is a short plan year return/report (less than 12 months)No
2021-10-01Plan is a collectively bargained planNo
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – InsuranceYes
2020: LUTHER BURBANK HEALTH PLAN 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Submission has been amendedNo
2020-10-01This submission is the final filingNo
2020-10-01This return/report is a short plan year return/report (less than 12 months)No
2020-10-01Plan is a collectively bargained planNo
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – InsuranceYes
2019: LUTHER BURBANK HEALTH PLAN 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Submission has been amendedNo
2019-10-01This submission is the final filingNo
2019-10-01This return/report is a short plan year return/report (less than 12 months)No
2019-10-01Plan is a collectively bargained planNo
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – InsuranceYes
2018: LUTHER BURBANK HEALTH PLAN 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01Submission has been amendedNo
2018-10-01This submission is the final filingNo
2018-10-01This return/report is a short plan year return/report (less than 12 months)No
2018-10-01Plan is a collectively bargained planNo
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – InsuranceYes
2017: LUTHER BURBANK HEALTH PLAN 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Submission has been amendedNo
2017-10-01This submission is the final filingNo
2017-10-01This return/report is a short plan year return/report (less than 12 months)No
2017-10-01Plan is a collectively bargained planNo
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – InsuranceYes
2016: LUTHER BURBANK HEALTH PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)No
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – InsuranceYes
2015: LUTHER BURBANK HEALTH PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – InsuranceYes
2014: LUTHER BURBANK HEALTH PLAN 2014 form 5500 responses
2014-10-01Type of plan entitySingle employer plan
2014-10-01Submission has been amendedNo
2014-10-01This submission is the final filingNo
2014-10-01This return/report is a short plan year return/report (less than 12 months)No
2014-10-01Plan is a collectively bargained planNo
2014-10-01Plan funding arrangement – InsuranceYes
2014-10-01Plan benefit arrangement – InsuranceYes
2013: LUTHER BURBANK HEALTH PLAN 2013 form 5500 responses
2013-10-01Type of plan entitySingle employer plan
2013-10-01Submission has been amendedNo
2013-10-01This submission is the final filingNo
2013-10-01This return/report is a short plan year return/report (less than 12 months)No
2013-10-01Plan is a collectively bargained planNo
2013-10-01Plan funding arrangement – InsuranceYes
2013-10-01Plan benefit arrangement – InsuranceYes
2012: LUTHER BURBANK HEALTH PLAN 2012 form 5500 responses
2012-10-01Type of plan entitySingle employer plan
2012-10-01First time form 5500 has been submittedYes
2012-10-01Submission has been amendedNo
2012-10-01This submission is the final filingNo
2012-10-01This return/report is a short plan year return/report (less than 12 months)No
2012-10-01Plan is a collectively bargained planNo
2012-10-01Plan funding arrangement – InsuranceYes
2012-10-01Plan benefit arrangement – InsuranceYes
2011: LUTHER BURBANK HEALTH PLAN 2011 form 5500 responses
2011-10-01Type of plan entitySingle employer plan
2011-10-01First time form 5500 has been submittedYes
2011-10-01Submission has been amendedNo
2011-10-01This submission is the final filingNo
2011-10-01This return/report is a short plan year return/report (less than 12 months)No
2011-10-01Plan is a collectively bargained planNo
2011-10-01Plan funding arrangement – InsuranceYes
2011-10-01Plan benefit arrangement – InsuranceYes
2010: LUTHER BURBANK HEALTH PLAN 2010 form 5500 responses
2010-10-01Type of plan entitySingle employer plan
2010-10-01First time form 5500 has been submittedYes
2010-10-01Submission has been amendedNo
2010-10-01This submission is the final filingNo
2010-10-01This return/report is a short plan year return/report (less than 12 months)No
2010-10-01Plan is a collectively bargained planNo
2010-10-01Plan funding arrangement – InsuranceYes
2010-10-01Plan benefit arrangement – InsuranceYes
2009: LUTHER BURBANK HEALTH PLAN 2009 form 5500 responses
2009-10-01Type of plan entitySingle employer plan
2009-10-01First time form 5500 has been submittedYes
2009-10-01Submission has been amendedNo
2009-10-01This submission is the final filingNo
2009-10-01This return/report is a short plan year return/report (less than 12 months)No
2009-10-01Plan is a collectively bargained planNo
2009-10-01Plan funding arrangement – InsuranceYes
2009-10-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232765
Policy instance 3
Insurance contract or identification number232765
Number of Individuals Covered127
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $39,763
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $993,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,763
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number604922
Policy instance 2
Insurance contract or identification number604922
Number of Individuals Covered101
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $30,286
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $711,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,286
Amount paid for insurance broker fees0
Insurance broker organization code?3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 1
Insurance contract or identification number151208
Number of Individuals Covered565
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $123,718
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,167,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $123,718
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number604922
Policy instance 2
Insurance contract or identification number604922
Number of Individuals Covered94
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $26,943
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $729,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,943
Amount paid for insurance broker fees0
Insurance broker organization code?3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 1
Insurance contract or identification number151208
Number of Individuals Covered545
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $138,259
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,998,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $138,259
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232765
Policy instance 3
Insurance contract or identification number232765
Number of Individuals Covered150
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $35,238
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $968,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,238
Amount paid for insurance broker fees0
Insurance broker organization code?3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 1
Insurance contract or identification number151208
Number of Individuals Covered578
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $153,177
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,748,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $153,177
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232765
Policy instance 2
Insurance contract or identification number232765
Number of Individuals Covered141
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $31,807
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $795,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,807
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number604922
Policy instance 3
Insurance contract or identification number604922
Number of Individuals Covered120
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $29,205
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $735,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,205
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232765
Policy instance 3
Insurance contract or identification number232765
Number of Individuals Covered110
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $26,774
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $672,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,774
Amount paid for insurance broker fees0
Insurance broker organization code?3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 1
Insurance contract or identification number151208
Number of Individuals Covered521
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $127,028
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,573,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $127,028
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number604922
Policy instance 2
Insurance contract or identification number604922
Number of Individuals Covered100
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $26,120
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $654,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,120
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number604922
Policy instance 2
Insurance contract or identification number604922
Number of Individuals Covered113
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $26,190
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $641,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232765
Policy instance 3
Insurance contract or identification number232765
Number of Individuals Covered106
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $26,448
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $664,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 1
Insurance contract or identification number151208
Number of Individuals Covered553
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $102,590
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,357,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 1
Insurance contract or identification number151208
Number of Individuals Covered177
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $103,264
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,450,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $103,264
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAMERICAP INSURANCE GROUP, LLC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number604922
Policy instance 2
Insurance contract or identification number604922
Number of Individuals Covered107
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $18,422
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $499,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,422
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAMERICAP INSURANCE GROUP, LLC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number232765
Policy instance 3
Insurance contract or identification number232765
Number of Individuals Covered93
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $15,173
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $422,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,173
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAMERICAP INSURANCE GROUP, LLC
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number892692
Policy instance 1
Insurance contract or identification number892692
Number of Individuals Covered285
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $38,525
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $383,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,525
Insurance broker organization code?3
Insurance broker nameAMERICAP INSURANCE GROUP, LLC
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 2
Insurance contract or identification number151208
Number of Individuals Covered268
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $134,656
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,456,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $134,656
Insurance broker organization code?3
Insurance broker nameAMERICAP INSURANCE GROUP, LLC
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 1
Insurance contract or identification number151208
Number of Individuals Covered257
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $99,602
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,529,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $99,602
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAMERICAP INSURANCE GROUP, LLC
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number892692
Policy instance 2
Insurance contract or identification number892692
Number of Individuals Covered269
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $30,442
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $306,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,442
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAMERICAP INSURANCE GROUP, LLC
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number892692
Policy instance 2
Insurance contract or identification number892692
Number of Individuals Covered189
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $24,385
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $245,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,385
Insurance broker organization code?3
Insurance broker nameBURKHOLDER CORPORATION
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 1
Insurance contract or identification number151208
Number of Individuals Covered171
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $79,832
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,151,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $79,832
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameBURKHOLDER CORPORATION
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number892692
Policy instance 2
Insurance contract or identification number892692
Number of Individuals Covered163
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $21,792
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $215,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 1
Insurance contract or identification number151208
Number of Individuals Covered163
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $88,326
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,642,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number892692
Policy instance 2
Insurance contract or identification number892692
Number of Individuals Covered159
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $12,122
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $121,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number151208
Policy instance 1
Insurance contract or identification number151208
Number of Individuals Covered137
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $69,096
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,403,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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