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MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 401k Plan overview

Plan NameMERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN
Plan identification number 501

MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

MERITAGE HEALTHCARE, LLC has sponsored the creation of one or more 401k plans.

Company Name:MERITAGE HEALTHCARE, LLC
Employer identification number (EIN):770547036
NAIC Classification:621610
NAIC Description:Home Health Care Services

Additional information about MERITAGE HEALTHCARE, LLC

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division
Incorporation Date: 2011-04-26
Company Identification Number: 603107801
Legal Registered Office Address: 15914 NE 26TH COURT

RIDGEFIELD
United States of America (USA)
98642

More information about MERITAGE HEALTHCARE, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-05-01HOLLEY SIMONEAU2023-11-15
5012021-05-01BROOKE CARNOHAN2022-10-31
5012020-05-01GORDON COPLEY2022-02-04
5012019-05-01BROOKE CARNOHAN2020-11-04
5012018-05-01BROOKE CARNOHAN2019-12-03
5012017-05-01
5012016-05-01BROOKE CARNOHAN
5012015-05-01BROOKE CARNOHAN
5012014-05-01BROOKE CARNOHAN
5012013-05-01BROOKE CARNOHAN
5012012-05-01BROOKE CARNOHAN
5012011-05-01CONNIE BEDNAREK
5012010-05-01CONNIE BEDNAREK

Plan Statistics for MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN

401k plan membership statisitcs for MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN

Measure Date Value
2022: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-05-01222
Total number of active participants reported on line 7a of the Form 55002022-05-01145
Number of retired or separated participants receiving benefits2022-05-011
Number of other retired or separated participants entitled to future benefits2022-05-017
Total of all active and inactive participants2022-05-01153
Number of employers contributing to the scheme2022-05-010
2021: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-05-01194
Total number of active participants reported on line 7a of the Form 55002021-05-01222
Number of retired or separated participants receiving benefits2021-05-010
Number of other retired or separated participants entitled to future benefits2021-05-010
Total of all active and inactive participants2021-05-01222
Number of employers contributing to the scheme2021-05-010
2020: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-05-01203
Total number of active participants reported on line 7a of the Form 55002020-05-01194
Number of retired or separated participants receiving benefits2020-05-010
Number of other retired or separated participants entitled to future benefits2020-05-010
Total of all active and inactive participants2020-05-01194
Number of employers contributing to the scheme2020-05-010
2019: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-05-01296
Total number of active participants reported on line 7a of the Form 55002019-05-01203
Number of retired or separated participants receiving benefits2019-05-010
Number of other retired or separated participants entitled to future benefits2019-05-010
Total of all active and inactive participants2019-05-01203
Number of employers contributing to the scheme2019-05-011
2018: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-05-01366
Total number of active participants reported on line 7a of the Form 55002018-05-01296
Number of retired or separated participants receiving benefits2018-05-010
Number of other retired or separated participants entitled to future benefits2018-05-010
Total of all active and inactive participants2018-05-01296
Number of employers contributing to the scheme2018-05-010
2017: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-05-01284
Total number of active participants reported on line 7a of the Form 55002017-05-01366
Number of retired or separated participants receiving benefits2017-05-010
Number of other retired or separated participants entitled to future benefits2017-05-010
Total of all active and inactive participants2017-05-01366
Number of employers contributing to the scheme2017-05-010
2016: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-01226
Total number of active participants reported on line 7a of the Form 55002016-05-01247
Number of retired or separated participants receiving benefits2016-05-011
Total of all active and inactive participants2016-05-01248
2015: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-05-01255
Total number of active participants reported on line 7a of the Form 55002015-05-01220
Total of all active and inactive participants2015-05-01220
2014: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-05-01266
Total number of active participants reported on line 7a of the Form 55002014-05-01247
Total of all active and inactive participants2014-05-01247
2013: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-05-01283
Total number of active participants reported on line 7a of the Form 55002013-05-01240
Total of all active and inactive participants2013-05-01240
2012: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-05-01239
Total number of active participants reported on line 7a of the Form 55002012-05-01278
Number of retired or separated participants receiving benefits2012-05-014
Number of other retired or separated participants entitled to future benefits2012-05-010
Total of all active and inactive participants2012-05-01282
2011: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-05-01270
Total number of active participants reported on line 7a of the Form 55002011-05-01239
Number of retired or separated participants receiving benefits2011-05-010
Number of other retired or separated participants entitled to future benefits2011-05-010
Total of all active and inactive participants2011-05-01239
2010: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-05-01185
Total number of active participants reported on line 7a of the Form 55002010-05-01270
Number of retired or separated participants receiving benefits2010-05-010
Number of other retired or separated participants entitled to future benefits2010-05-010
Total of all active and inactive participants2010-05-01270

Form 5500 Responses for MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN

2022: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-05-01Type of plan entitySingle employer plan
2022-05-01Plan funding arrangement – InsuranceYes
2022-05-01Plan benefit arrangement – InsuranceYes
2021: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-05-01Type of plan entitySingle employer plan
2021-05-01Plan funding arrangement – InsuranceYes
2021-05-01Plan benefit arrangement – InsuranceYes
2020: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-05-01Type of plan entitySingle employer plan
2020-05-01Plan funding arrangement – InsuranceYes
2020-05-01Plan benefit arrangement – InsuranceYes
2019: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-05-01Type of plan entitySingle employer plan
2019-05-01Plan funding arrangement – InsuranceYes
2019-05-01Plan benefit arrangement – InsuranceYes
2018: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-05-01Type of plan entitySingle employer plan
2018-05-01Plan funding arrangement – InsuranceYes
2018-05-01Plan benefit arrangement – InsuranceYes
2017: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-05-01Type of plan entitySingle employer plan
2017-05-01Plan funding arrangement – InsuranceYes
2017-05-01Plan benefit arrangement – InsuranceYes
2016: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-05-01Type of plan entitySingle employer plan
2016-05-01Submission has been amendedNo
2016-05-01This submission is the final filingNo
2016-05-01This return/report is a short plan year return/report (less than 12 months)No
2016-05-01Plan is a collectively bargained planNo
2016-05-01Plan funding arrangement – InsuranceYes
2016-05-01Plan benefit arrangement – InsuranceYes
2015: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-05-01Type of plan entitySingle employer plan
2015-05-01Submission has been amendedNo
2015-05-01This submission is the final filingNo
2015-05-01This return/report is a short plan year return/report (less than 12 months)No
2015-05-01Plan is a collectively bargained planNo
2015-05-01Plan funding arrangement – InsuranceYes
2015-05-01Plan benefit arrangement – InsuranceYes
2014: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-05-01Type of plan entitySingle employer plan
2014-05-01Submission has been amendedNo
2014-05-01This submission is the final filingNo
2014-05-01This return/report is a short plan year return/report (less than 12 months)No
2014-05-01Plan is a collectively bargained planNo
2014-05-01Plan funding arrangement – InsuranceYes
2014-05-01Plan benefit arrangement – InsuranceYes
2013: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-05-01Type of plan entitySingle employer plan
2013-05-01Submission has been amendedNo
2013-05-01This submission is the final filingNo
2013-05-01This return/report is a short plan year return/report (less than 12 months)No
2013-05-01Plan is a collectively bargained planNo
2013-05-01Plan funding arrangement – General assets of the sponsorYes
2013-05-01Plan benefit arrangement – InsuranceYes
2012: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-05-01Type of plan entitySingle employer plan
2012-05-01Submission has been amendedNo
2012-05-01This submission is the final filingNo
2012-05-01This return/report is a short plan year return/report (less than 12 months)No
2012-05-01Plan is a collectively bargained planNo
2012-05-01Plan funding arrangement – General assets of the sponsorYes
2012-05-01Plan benefit arrangement – InsuranceYes
2011: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-05-01Type of plan entitySingle employer plan
2011-05-01Submission has been amendedNo
2011-05-01This submission is the final filingNo
2011-05-01This return/report is a short plan year return/report (less than 12 months)No
2011-05-01Plan is a collectively bargained planNo
2011-05-01Plan funding arrangement – General assets of the sponsorYes
2011-05-01Plan benefit arrangement – InsuranceYes
2010: MERITAGE HEALTHCARE, LLC WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-05-01Type of plan entitySingle employer plan
2010-05-01First time form 5500 has been submittedYes
2010-05-01Submission has been amendedNo
2010-05-01This submission is the final filingNo
2010-05-01This return/report is a short plan year return/report (less than 12 months)No
2010-05-01Plan is a collectively bargained planNo
2010-05-01Plan funding arrangement – General assets of the sponsorYes
2010-05-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD606588
Policy instance 6
Insurance contract or identification numberSGD606588
Number of Individuals Covered145
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $7,901
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $52,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $7,901
Amount paid for insurance broker fees0
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053214
Policy instance 5
Insurance contract or identification numberW0053214
Number of Individuals Covered157
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $84,052
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,564,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees84052
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 4
Insurance contract or identification number30025842
Number of Individuals Covered161
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $1,925
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,361
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,925
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 3
Insurance contract or identification number627617
Number of Individuals Covered17
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $3,373
Total amount of fees paid to insurance companyUSD $26
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $116,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,373
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3340900
Policy instance 2
Insurance contract or identification number3340900
Number of Individuals Covered179
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $12,177
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $141,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,177
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0053214
Policy instance 1
Insurance contract or identification numberW0053214
Number of Individuals Covered124
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $714
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $7,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $714
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0053214
Policy instance 1
Insurance contract or identification numberW0053214
Number of Individuals Covered113
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $640
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $6,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $640
Amount paid for insurance broker fees0
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3340900
Policy instance 2
Insurance contract or identification number3340900
Number of Individuals Covered175
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $12,721
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $147,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,721
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 3
Insurance contract or identification number627617
Number of Individuals Covered7
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $3,576
Total amount of fees paid to insurance companyUSD $117
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $138,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,576
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 4
Insurance contract or identification number30025842
Number of Individuals Covered152
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $2,458
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,298
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,458
Amount paid for insurance broker fees0
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053214
Policy instance 5
Insurance contract or identification numberW0053214
Number of Individuals Covered138
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $76,603
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,585,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees76603
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM606383
Policy instance 6
Insurance contract or identification numberSGM606383
Number of Individuals Covered222
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $9,046
Total amount of fees paid to insurance companyUSD $1,360
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $61,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $9,046
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerOVERRIDE
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0053214
Policy instance 1
Insurance contract or identification numberW0053214
Number of Individuals Covered128
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $841
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $841
Amount paid for insurance broker fees0
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3340900
Policy instance 2
Insurance contract or identification number3340900
Number of Individuals Covered194
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $13,462
Total amount of fees paid to insurance companyUSD $3,512
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $154,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,462
Amount paid for insurance broker fees3512
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 3
Insurance contract or identification number627617
Number of Individuals Covered13
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $4,275
Total amount of fees paid to insurance companyUSD $145
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $151,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,275
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 4
Insurance contract or identification number30025842
Number of Individuals Covered166
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $2,721
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,721
Amount paid for insurance broker fees0
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053214
Policy instance 5
Insurance contract or identification numberW0053214
Number of Individuals Covered158
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $90,632
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,656,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees90632
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES BONUS OVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM606383
Policy instance 6
Insurance contract or identification numberSGM606383
Number of Individuals Covered194
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $8,523
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $58,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $8,493
Amount paid for insurance broker fees0
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053214
Policy instance 5
Insurance contract or identification numberW0053214
Number of Individuals Covered167
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $82,644
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,570,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees82644
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 4
Insurance contract or identification number30025842
Number of Individuals Covered173
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $2,927
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $29,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,927
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 3
Insurance contract or identification number627617
Number of Individuals Covered21
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $4,092
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $132,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,558
Amount paid for insurance broker fees0
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3340900
Policy instance 2
Insurance contract or identification number3340900
Number of Individuals Covered203
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $15,860
Total amount of fees paid to insurance companyUSD $960
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $179,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,549
Amount paid for insurance broker fees960
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
Insurance broker organization code?3
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0053214
Policy instance 1
Insurance contract or identification numberW0053214
Number of Individuals Covered203
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $821
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $821
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM606383
Policy instance 6
Insurance contract or identification numberSGM606383
Number of Individuals Covered203
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $8,849
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $59,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $8,849
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 4
Insurance contract or identification number30025842
Number of Individuals Covered194
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $3,019
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $31,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,019
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0053214
Policy instance 1
Insurance contract or identification numberW0053214
Number of Individuals Covered140
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $819
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $794
Amount paid for insurance broker fees0
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3340900
Policy instance 2
Insurance contract or identification number3340900
Number of Individuals Covered231
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $16,268
Total amount of fees paid to insurance companyUSD $1,068
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $186,473
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,268
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 3
Insurance contract or identification number627617
Number of Individuals Covered19
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $4,193
Total amount of fees paid to insurance companyUSD $42
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $100,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,193
Amount paid for insurance broker fees42
Additional information about fees paid to insurance brokerBONUS NON-MONETARY COMPENSATION
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053214
Policy instance 5
Insurance contract or identification numberW0053214
Number of Individuals Covered178
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $85,310
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,706,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,562
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM606383
Policy instance 6
Insurance contract or identification numberSGM606383
Number of Individuals Covered296
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $11,351
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $70,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $10,054
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0053214
Policy instance 1
Insurance contract or identification numberW0053214
Number of Individuals Covered91
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $552
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $5,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $552
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameBOLTON AND COMPANY
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number6D50
Policy instance 2
Insurance contract or identification number6D50
Number of Individuals Covered47
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $1,416
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,416
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3340900
Policy instance 3
Insurance contract or identification number3340900
Number of Individuals Covered173
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $15,879
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $160,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,879
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameBOLTON AND COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 4
Insurance contract or identification number627617
Number of Individuals Covered13
Insurance policy start date2016-12-01
Insurance policy end date2017-11-30
Total amount of commissions paid to insurance brokerUSD $2,602
Total amount of fees paid to insurance companyUSD $143
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $58,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,602
Amount paid for insurance broker fees143
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameBOLTON AND COMPANY
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 5
Insurance contract or identification number30025842
Number of Individuals Covered111
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $2,892
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,892
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameBOLTON AND COMPANY
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053214
Policy instance 6
Insurance contract or identification numberW0053214
Number of Individuals Covered96
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $71,441
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,428,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $71,441
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameBOLTON AND COMPANY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM606383
Policy instance 7
Insurance contract or identification numberSGM606383
Number of Individuals Covered366
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $9,477
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $70,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $9,477
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameBOLTON AND COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 5
Insurance contract or identification number627617
Number of Individuals Covered10
Insurance policy start date2014-12-01
Insurance policy end date2015-11-30
Total amount of commissions paid to insurance brokerUSD $1,941
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $49,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,941
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 9
Insurance contract or identification number30025842
Number of Individuals Covered147
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $2,350
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,350
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0053214
Policy instance 1
Insurance contract or identification numberW0053214
Number of Individuals Covered87
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $252
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $252
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053214
Policy instance 2
Insurance contract or identification numberW0053214
Number of Individuals Covered94
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $50,292
Total amount of fees paid to insurance companyUSD $3,060
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,005,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $50,292
Amount paid for insurance broker fees3060
Additional information about fees paid to insurance brokerBONUS OVERIDE ALLOCATION
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number6D50
Policy instance 3
Insurance contract or identification number6D50
Number of Individuals Covered16
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $713
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $713
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00512087
Policy instance 4
Insurance contract or identification number00512087
Number of Individuals Covered169
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $19,401
Total amount of fees paid to insurance companyUSD $3,686
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $153,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,374
Amount paid for insurance broker fees3686
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameASSUREX AGENCY INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK604508
Policy instance 6
Insurance contract or identification numberSOK604508
Number of Individuals Covered215
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $823
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedBASIC & VOLUNTARY 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 CarrierUSD $5,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $823
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSDG606588
Policy instance 7
Insurance contract or identification numberSDG606588
Number of Individuals Covered216
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $3,300
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,300
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM606383
Policy instance 8
Insurance contract or identification numberSGM606383
Number of Individuals Covered220
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $4,246
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE INSURANCE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $30,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,246
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10159156
Policy instance 3
Insurance contract or identification number10159156
Number of Individuals Covered242
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $1,666
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,666
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10159157
Policy instance 2
Insurance contract or identification number10159157
Number of Individuals Covered248
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $3,164
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,164
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 4
Insurance contract or identification number30025842
Number of Individuals Covered154
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $1,221
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,221
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0053214
Policy instance 6
Insurance contract or identification numberW0053214
Number of Individuals Covered78
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $219
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $219
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053214
Policy instance 7
Insurance contract or identification numberW0053214
Number of Individuals Covered85
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $42,766
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $855,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,766
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number902080-399
Policy instance 5
Insurance contract or identification number902080-399
Number of Individuals Covered199
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $15,755
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $158,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,755
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 8
Insurance contract or identification number627617
Number of Individuals Covered10
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $1,758
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $62,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,758
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number6D50
Policy instance 1
Insurance contract or identification number6D50
Number of Individuals Covered17
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $845
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $845
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10159156
Policy instance 2
Insurance contract or identification number10159156
Number of Individuals Covered245
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $1,855
Total amount of fees paid to insurance companyUSD $363
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,855
Amount paid for insurance broker fees363
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10159157
Policy instance 3
Insurance contract or identification number10159157
Number of Individuals Covered250
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $3,504
Total amount of fees paid to insurance companyUSD $678
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,360
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,504
Amount paid for insurance broker fees678
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number40000100015137
Policy instance 4
Insurance contract or identification number40000100015137
Number of Individuals Covered54
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $3,155
Total amount of fees paid to insurance companyUSD $491
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,155
Amount paid for insurance broker fees491
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number303256
Policy instance 9
Insurance contract or identification number303256
Number of Individuals Covered78
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $260
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $260
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number403001684
Policy instance 5
Insurance contract or identification number403001684
Number of Individuals Covered8
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $40
Total amount of fees paid to insurance companyUSD $6
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40
Amount paid for insurance broker fees6
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 6
Insurance contract or identification number30025842
Number of Individuals Covered141
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $1,168
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,168
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY INSURANCE BROKERS
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number902080-399
Policy instance 10
Insurance contract or identification number902080-399
Number of Individuals Covered179
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $14,291
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $141,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,291
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 8
Insurance contract or identification number627617
Number of Individuals Covered10
Insurance policy start date2012-12-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $2,417
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $71,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,417
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number6D50
Policy instance 7
Insurance contract or identification number6D50
Number of Individuals Covered25
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $1,381
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,381
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number744381
Policy instance 1
Insurance contract or identification number744381
Number of Individuals Covered132
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $43,891
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $877,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,891
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number403001684
Policy instance 10
Insurance contract or identification number403001684
Number of Individuals Covered4
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $52
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32
Insurance broker organization code?3
Insurance broker nameBRADLEY REAUME INSURANCE SERVICE
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00477010
Policy instance 9
Insurance contract or identification number00477010
Number of Individuals Covered167
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $12,752
Total amount of fees paid to insurance companyUSD $4,732
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $127,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,533
Amount paid for insurance broker fees4732
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDES
Insurance broker organization code?3
Insurance broker nameBRADLEY REAUME INSURANCE SERVICE
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 8
Insurance contract or identification number30025842
Number of Individuals Covered142
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $1,162
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $627
Insurance broker organization code?3
Insurance broker nameBRADLEY REAUME INSURANCE SERVICE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number400001000 15137
Policy instance 7
Insurance contract or identification number400001000 15137
Number of Individuals Covered71
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $2,880
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,124
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 5
Insurance contract or identification number627617
Number of Individuals Covered15
Insurance policy start date2011-12-01
Insurance policy end date2012-11-30
Total amount of commissions paid to insurance brokerUSD $2,167
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $57,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,356
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10159157
Policy instance 4
Insurance contract or identification number10159157
Number of Individuals Covered286
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $3,759
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $25,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,810
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10159156
Policy instance 3
Insurance contract or identification number10159156
Number of Individuals Covered278
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $2,000
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,832
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )
Policy contract number303256
Policy instance 2
Insurance contract or identification number303256
Number of Individuals Covered89
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $220
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $220
Insurance broker organization code?3
Insurance broker nameBRADLEY REAUME INSURANCE SERVICE
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number6D50
Policy instance 6
Insurance contract or identification number6D50
Number of Individuals Covered36
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $1,816
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,816
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number744381
Policy instance 1
Insurance contract or identification number744381
Number of Individuals Covered131
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $41,302
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $826,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,869
Insurance broker organization code?3
Insurance broker nameBRADLEY REAUME INSURANCE SERVICE
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30025842
Policy instance 2
Insurance contract or identification number30025842
Number of Individuals Covered123
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $1,090
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,564
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 number805259
Policy instance 1
Insurance contract or identification number805259
Number of Individuals Covered137
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $42,309
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $861,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number627617
Policy instance 3
Insurance contract or identification number627617
Number of Individuals Covered8
Insurance policy start date2010-12-01
Insurance policy end date2011-11-30
Total amount of commissions paid to insurance brokerUSD $1,553
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $43,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF1D0145
Policy instance 4
Insurance contract or identification numberF1D0145
Number of Individuals Covered144
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $9,757
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $111,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number06871
Policy instance 5
Insurance contract or identification number06871
Number of Individuals Covered239
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $6,942
Total amount of fees paid to insurance companyUSD $91
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $46,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number6D50
Policy instance 6
Insurance contract or identification number6D50
Number of Individuals Covered52
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $2,341
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF1D0145
Policy instance 2
Insurance contract or identification numberF1D0145
Number of Individuals Covered149
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $8,440
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $89,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberF30215(23600)
Policy instance 4
Insurance contract or identification numberF30215(23600)
Number of Individuals Covered120
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $1,499
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,867
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 number805259
Policy instance 1
Insurance contract or identification number805259
Number of Individuals Covered148
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $34,908
Total amount of fees paid to insurance companyUSD $26
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $737,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number06871
Policy instance 5
Insurance contract or identification number06871
Number of Individuals Covered270
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $6,750
Total amount of fees paid to insurance companyUSD $84
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $45,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number6D50
Policy instance 3
Insurance contract or identification number6D50
Number of Individuals Covered57
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $2,714
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $27,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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