VISTA FAMILY OF COMPANIES has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan XOJET, INC. GROUP HEALTH PLAN
401k plan membership statisitcs for XOJET, INC. GROUP HEALTH PLAN
| Measure | Date | Value |
|---|
| 2022: XOJET, INC. GROUP HEALTH PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 518 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 514 |
| 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 | 514 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: XOJET, INC. GROUP HEALTH PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 603 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 518 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| 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 | 518 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: XOJET, INC. GROUP HEALTH PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 528 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 603 |
| 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 | 603 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: XOJET, INC. GROUP HEALTH PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 459 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 528 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| 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 | 528 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: XOJET, INC. GROUP HEALTH PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 430 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 459 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| 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 | 459 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: XOJET, INC. GROUP HEALTH PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 421 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 430 |
| 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 | 430 |
| 2016: XOJET, INC. GROUP HEALTH PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 340 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 421 |
| 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 | 421 |
| 2015: XOJET, INC. GROUP HEALTH PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 410 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 340 |
| 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 | 340 |
| 2014: XOJET, INC. GROUP HEALTH PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 501 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 410 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 410 |
| 2013: XOJET, INC. GROUP HEALTH PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 380 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 412 |
| Total of all active and inactive participants | 2013-01-01 | 412 |
| 2012: XOJET, INC. GROUP HEALTH PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-11-01 | 377 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-11-01 | 380 |
| Number of retired or separated participants receiving benefits | 2012-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-11-01 | 0 |
| Total of all active and inactive participants | 2012-11-01 | 380 |
| 2011: XOJET, INC. GROUP HEALTH PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-11-01 | 264 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-11-01 | 377 |
| Total of all active and inactive participants | 2011-11-01 | 377 |
| 2009: XOJET, INC. GROUP HEALTH PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-11-01 | 234 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-11-01 | 244 |
| Number of retired or separated participants receiving benefits | 2009-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-11-01 | 0 |
| Total of all active and inactive participants | 2009-11-01 | 244 |
| 2022: XOJET, INC. GROUP HEALTH PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: XOJET, INC. GROUP HEALTH PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: XOJET, INC. GROUP HEALTH PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: XOJET, INC. GROUP HEALTH PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: XOJET, INC. GROUP HEALTH PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: XOJET, INC. GROUP HEALTH PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: XOJET, INC. GROUP HEALTH PLAN 2016 form 5500 responses |
|---|
| 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: XOJET, INC. GROUP HEALTH PLAN 2015 form 5500 responses |
|---|
| 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: XOJET, INC. GROUP HEALTH PLAN 2014 form 5500 responses |
|---|
| 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: XOJET, INC. GROUP HEALTH PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: XOJET, INC. GROUP HEALTH PLAN 2012 form 5500 responses |
|---|
| 2012-11-01 | Type of plan entity | Single employer plan |
| 2012-11-01 | Submission has been amended | No |
| 2012-11-01 | This submission is the final filing | No |
| 2012-11-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2012-11-01 | Plan is a collectively bargained plan | No |
| 2012-11-01 | Plan funding arrangement – Insurance | Yes |
| 2012-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: XOJET, INC. GROUP HEALTH PLAN 2011 form 5500 responses |
|---|
| 2011-11-01 | Type of plan entity | Single employer plan |
| 2011-11-01 | Submission has been amended | No |
| 2011-11-01 | This submission is the final filing | No |
| 2011-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-11-01 | Plan is a collectively bargained plan | No |
| 2011-11-01 | Plan funding arrangement – Insurance | Yes |
| 2011-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: XOJET, INC. GROUP HEALTH PLAN 2009 form 5500 responses |
|---|
| 2009-11-01 | Type of plan entity | Single employer plan |
| 2009-11-01 | Submission has been amended | No |
| 2009-11-01 | This submission is the final filing | No |
| 2009-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-11-01 | Plan is a collectively bargained plan | No |
| 2009-11-01 | Plan funding arrangement – Insurance | Yes |
| 2009-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017594-00 |
| Policy instance | 3 |
| Insurance contract or identification number | 01-017594-00 | | Number of Individuals Covered | 514 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $125,471 | | Total amount of fees paid to insurance company | USD $39,478 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $954,954 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $125,471 | | Amount paid for insurance broker fees | 39478 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 748 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $12,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 819363 |
| Policy instance | 1 |
| Insurance contract or identification number | 819363 | | Number of Individuals Covered | 1137 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $49,856 | | Total amount of fees paid to insurance company | USD $28,108 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,525,916 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,856 | | Amount paid for insurance broker fees | 28108 | | Additional information about fees paid to insurance broker | 2021 MEDICAL RETENTION INCENTIVE, INDIRECT COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30036668 |
| Policy instance | 5 |
| Insurance contract or identification number | 30036668 | | Number of Individuals Covered | 766 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,609 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $135,259 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,609 | | 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 | ETB119258 |
| Policy instance | 4 |
| Insurance contract or identification number | ETB119258 | | Number of Individuals Covered | 514 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $1,350 | | Total amount of fees paid to insurance company | USD $203 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $13,504 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,350 | | Amount paid for insurance broker fees | 203 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 819363 |
| Policy instance | 1 |
| Insurance contract or identification number | 819363 | | Number of Individuals Covered | 1133 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $259,983 | | Total amount of fees paid to insurance company | USD $26,859 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,405,662 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $259,983 | | Amount paid for insurance broker fees | 26800 | | Additional information about fees paid to insurance broker | 2020 PINNACLE MEDICAL RETENTION INCENTIVE RISK | | Insurance broker organization code? | 3 |
|
| COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 737 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $11,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 134412 |
| Policy instance | 3 |
| Insurance contract or identification number | 134412 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $284 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $1,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $222 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 4 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB119258 |
| Policy instance | 5 |
| Insurance contract or identification number | ETB119258 | | Number of Individuals Covered | 518 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $1,350 | | Total amount of fees paid to insurance company | USD $203 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $13,504 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,350 | | Amount paid for insurance broker fees | 203 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30036668 |
| Policy instance | 6 |
| Insurance contract or identification number | 30036668 | | Number of Individuals Covered | 664 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $5,567 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $191,515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,567 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017594-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-017594-00 | | Number of Individuals Covered | 518 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $112,244 | | Total amount of fees paid to insurance company | USD $45,609 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $860,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $112,244 | | Amount paid for insurance broker fees | 45609 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 663 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $9,040 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 819363 |
| Policy instance | 1 |
| Insurance contract or identification number | 819363 | | Number of Individuals Covered | 1127 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $124,664 | | Total amount of fees paid to insurance company | USD $35,500 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,278,268 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $124,664 | | Amount paid for insurance broker fees | 35500 | | Additional information about fees paid to insurance broker | 2019 PPP SPECIALTY RETENTION RISK 2019 PPP MEDICAL RETENTION RISK | | Insurance broker organization code? | 3 |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 134412 |
| Policy instance | 3 |
| Insurance contract or identification number | 134412 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $368 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $2,114 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $284 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 4 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017594-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-017594-00 | | Number of Individuals Covered | 603 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $112,803 | | Total amount of fees paid to insurance company | USD $41,798 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $863,705 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $112,803 | | Amount paid for insurance broker fees | 41798 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB119258 |
| Policy instance | 5 |
| Insurance contract or identification number | ETB119258 | | Number of Individuals Covered | 603 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $1,193 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,956 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,193 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30036668 |
| Policy instance | 6 |
| Insurance contract or identification number | 30036668 | | Number of Individuals Covered | 629 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $256 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,431 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $256 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 819363 |
| Policy instance | 1 |
| Insurance contract or identification number | 819363 | | Number of Individuals Covered | 892 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $172,657 | | Total amount of fees paid to insurance company | USD $4,381 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,408,417 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $172,657 | | Amount paid for insurance broker fees | 4219 | | Additional information about fees paid to insurance broker | 2018 PREMIER PRODUCER MEDICAL RETENTION | | Insurance broker organization code? | 3 |
|
| COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 445 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $6,889 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 134412 |
| Policy instance | 3 |
| Insurance contract or identification number | 134412 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $377 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $2,485 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $244 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017594-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-017594-00 | | Number of Individuals Covered | 432 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $60,576 | | Total amount of fees paid to insurance company | USD $11,431 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $464,879 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,576 | | Amount paid for insurance broker fees | 11431 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB119258 |
| Policy instance | 5 |
| Insurance contract or identification number | ETB119258 | | Number of Individuals Covered | 528 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $1,938 | | Total amount of fees paid to insurance company | USD $2,273 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,921 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 2273 | | Additional information about fees paid to insurance broker | FEES BONUS | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL139577 |
| Policy instance | 4 |
| Insurance contract or identification number | GL139577 | | Number of Individuals Covered | 430 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $81,608 | | Total amount of fees paid to insurance company | USD $8,489 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $597,447 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $81,608 | | Amount paid for insurance broker fees | 8489 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ALLIANT INSURANCE SERVICES, INC. |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB119258 |
| Policy instance | 3 |
| Insurance contract or identification number | ETB119258 | | Number of Individuals Covered | 430 | | Insurance policy start date | 2016-12-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $2,126 | | Total amount of fees paid to insurance company | USD $2,906 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $14,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 2906 | | Additional information about fees paid to insurance broker | FEES BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | CRYSTAL & COMPANY |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 134412 |
| Policy instance | 2 |
| Insurance contract or identification number | 134412 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $936 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $3,952 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $545 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 4 | | Insurance broker name | ELIZABETH M. REIN |
|
| MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 1354 |
| Policy instance | 1 |
| Insurance contract or identification number | 1354 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $454 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $9,078 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $454 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ALLIANT INSURANCE SERVICES, INC. |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 134412 |
| Policy instance | 5 |
| Insurance contract or identification number | 134412 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,021 | | 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 | LEGAL | | 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 $7,070 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $791 | | Insurance broker organization code? | 4 | | Insurance broker name | CLEARPOINT, LLC |
|
| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 13713 |
| Policy instance | 1 |
| Insurance contract or identification number | 13713 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | 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 | 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 $4,749 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL139577 |
| Policy instance | 2 |
| Insurance contract or identification number | GL139577 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $34,696 | | Total amount of fees paid to insurance company | USD $3,972 | | 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 | | 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 $245,440 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,696 | | Amount paid for insurance broker fees | 3972 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ALLIANT INSURANCE SERVICES, INC. |
|
| MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 1354 |
| Policy instance | 3 |
| Insurance contract or identification number | 1354 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $554 | | 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 | 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 $11,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $554 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEARPOINT, LLC |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB119258 |
| Policy instance | 4 |
| Insurance contract or identification number | ETB119258 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $2,126 | | Total amount of fees paid to insurance company | USD $2,410 | | 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 | BUSINESS TRAVEL ACCIDENT | | 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 $14,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,126 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2410 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | RUEBEN WARNER AND ASSOCIATES |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL139577 |
| Policy instance | 2 |
| Insurance contract or identification number | GL139577 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $28,554 | | Total amount of fees paid to insurance company | USD $2,487 | | 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 | | 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 $198,608 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,554 | | Amount paid for insurance broker fees | 2487 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | KEVIN OBERBEY |
|
| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 13713 |
| Policy instance | 1 |
| Insurance contract or identification number | 13713 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | 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 | 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 $4,802 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 1354 |
| Policy instance | 3 |
| Insurance contract or identification number | 1354 | | Number of Individuals Covered | 410 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $550 | | 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 | 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 $10,999 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $550 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEARPOINT |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP9129184 |
| Policy instance | 4 |
| Insurance contract or identification number | GTP9129184 | | Number of Individuals Covered | 368 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $1,958 | | Total amount of fees paid to insurance company | USD $1,958 | | 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 | BUSINESS TRAVEL ACCIDENT | | 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 $13,052 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,958 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1958 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | REUBEN WARNER ASSOCIATES, INC. |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 134412 |
| Policy instance | 5 |
| Insurance contract or identification number | 134412 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,125 | | 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 | LEGAL | | 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 $7,500 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $993 | | Insurance broker organization code? | 4 | | Insurance broker name | ABRAHAM P. JABALLA |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 610051 |
| Policy instance | 7 |
| Insurance contract or identification number | G 610051 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $122 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,112 | | 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 | | Insurance broker organization code? | 3 | | Insurance broker name | OVERBEY, KEVIN |
|
| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 13713 |
| Policy instance | 6 |
| Insurance contract or identification number | 13713 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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 | 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 $4,891 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 179414 |
| Policy instance | 5 |
| Insurance contract or identification number | VG 179414 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,601 | | 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 | 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 $28,793 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,601 | | Insurance broker organization code? | 3 | | Insurance broker name | OVERBEY, KEVIN |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 113554 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD 113554 | | Number of Individuals Covered | 412 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $13,321 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $103,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,321 | | Insurance broker organization code? | 3 | | Insurance broker name | OVERBEY, KEVIN |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 139577 |
| Policy instance | 3 |
| Insurance contract or identification number | GL 139577 | | Number of Individuals Covered | 412 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $11,407 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $69,237 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,407 | | Insurance broker organization code? | 3 | | Insurance broker name | OVERBEY, KEVIN |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G157415 |
| Policy instance | 2 |
| Insurance contract or identification number | G157415 | | Number of Individuals Covered | 412 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $4,415 | | 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 | Yes | | 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 $26,668 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,415 | | Insurance broker organization code? | 3 | | Insurance broker name | OVERBEY, KEVIN |
|
| MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 1354 |
| Policy instance | 1 |
| Insurance contract or identification number | 1354 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $462 | | 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 | EMPLOYEE ASSISTANCE PLAN | | 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 $9,218 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $462 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEARPOINT |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 9129184 |
| Policy instance | 8 |
| Insurance contract or identification number | GTP 9129184 | | Number of Individuals Covered | 410 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,958 | | Total amount of fees paid to insurance company | USD $1,958 | | 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 | BUSINESS TRAVEL ACCIDENT | | 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 $13,056 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,958 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1958 | | Additional information about fees paid to insurance broker | AGENCY FEE | | Insurance broker name | REUBEN WARNER |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 610051 |
| Policy instance | 7 |
| Insurance contract or identification number | G 610051 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $23 | | 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 | Yes | | 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 $209 | | Commission paid to Insurance Broker | USD $23 | | Insurance broker organization code? | 3 | | Insurance broker name | OVERBEY, KEVIN |
|
| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 13713 |
| Policy instance | 6 |
| Insurance contract or identification number | 13713 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2012-12-31 | | 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 | 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 $821 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 179414 |
| Policy instance | 5 |
| Insurance contract or identification number | VG 179414 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $549 | | 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 | 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 $5,494 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $549 | | Insurance broker organization code? | 3 | | Insurance broker name | KEVIN T. OVERBEY |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 113554 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD 113554 | | Number of Individuals Covered | 380 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,168 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,455 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,168 | | Insurance broker organization code? | 3 | | Insurance broker name | KEVIN T. OVERBEY |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 139577 |
| Policy instance | 3 |
| Insurance contract or identification number | GL 139577 | | Number of Individuals Covered | 380 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $1,422 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,478 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,422 | | Insurance broker organization code? | 3 | | Insurance broker name | KEVIN T. OVERBEY |
|
| MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 1354 |
| Policy instance | 1 |
| Insurance contract or identification number | 1354 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $89 | | 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 | EMPLOYEE ASSISTANCE PLAN | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $89 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEARPOINT |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 157415 |
| Policy instance | 2 |
| Insurance contract or identification number | G 157415 | | Number of Individuals Covered | 380 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $463 | | 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 | Yes | | 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 $3,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $463 | | Insurance broker organization code? | 3 | | Insurance broker name | OVERBEY, KEVIN |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 139577 |
| Policy instance | 5 |
| Insurance contract or identification number | GL 139577 | | Number of Individuals Covered | 377 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $7,841 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $52,271 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 113554 |
| Policy instance | 6 |
| Insurance contract or identification number | LTD 113554 | | Number of Individuals Covered | 377 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $11,962 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $79,749 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 179414 |
| Policy instance | 7 |
| Insurance contract or identification number | VG 179414 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $2,950 | | 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 | 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 $29,500 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 04609A |
| Policy instance | 1 |
| Insurance contract or identification number | 04609A | | Number of Individuals Covered | 16 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $8,799 | | 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 | 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 | EVACUATION COVERAGE AND IEAP COVERAGE | | 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 $76,737 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 157415 |
| Policy instance | 4 |
| Insurance contract or identification number | G 157415 | | Number of Individuals Covered | 377 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $2,572 | | 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 | Yes | | 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 $17,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 1354 |
| Policy instance | 3 |
| Insurance contract or identification number | 1354 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $485 | | 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 | EAP PLAN PREMIUMS | | 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 $10,600 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 13713 |
| Policy instance | 2 |
| Insurance contract or identification number | 13713 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | 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 | 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 $15,609 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 13713 |
| Policy instance | 2 |
| Insurance contract or identification number | 13713 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | 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 | 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 $20,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 179414 |
| Policy instance | 7 |
| Insurance contract or identification number | VG 179414 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $2,395 | | 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 | 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 $23,951 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 113554 |
| Policy instance | 6 |
| Insurance contract or identification number | LTD 113554 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $10,919 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $72,793 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 819363 |
| Policy instance | 1 |
| Insurance contract or identification number | 819363 | | Number of Individuals Covered | 244 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $115,941 | | Total amount of fees paid to insurance company | USD $10,260 | | 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 $2,346,708 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 139577 |
| Policy instance | 5 |
| Insurance contract or identification number | GL 139577 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $7,155 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $47,669 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 157415 |
| Policy instance | 4 |
| Insurance contract or identification number | G 157415 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $2,324 | | 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 | Yes | | 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 $15,495 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 1354 |
| Policy instance | 3 |
| Insurance contract or identification number | 1354 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $393 | | 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 | EAP PLAN PREMIUMS | | 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 $7,865 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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