XPERI CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan XPERI CORPORATION HEALTH AND WELFARE PLAN
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
Policy contract number | 154708 |
Policy instance | 9 |
Insurance contract or identification number | 154708 | Number of Individuals Covered | 329 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $57,864 | Total amount of fees paid to insurance company | USD $5,339 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $57,864 | Amount paid for insurance broker fees | 5339 | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 915712 |
Policy instance | 1 |
Insurance contract or identification number | 915712 | Number of Individuals Covered | 725 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $225,095 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $5,586,290 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $225,095 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
Policy contract number | 010-051795 |
Policy instance | 2 |
Insurance contract or identification number | 010-051795 | Number of Individuals Covered | 695 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $3,762 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $75,235 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,762 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 ) |
Policy contract number | 690 |
Policy instance | 3 |
Insurance contract or identification number | 690 | Number of Individuals Covered | 329 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $613 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $12,267 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $613 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | ETB151161 |
Policy instance | 4 |
Insurance contract or identification number | ETB151161 | Number of Individuals Covered | 0 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $342 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $2,282 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $342 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 05158A |
Policy instance | 5 |
Insurance contract or identification number | 05158A | Number of Individuals Covered | 1 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $2,496 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $24,955 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $2,496 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 537536 |
Policy instance | 6 |
Insurance contract or identification number | 537536 | Number of Individuals Covered | 380 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $8,392 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LONG TERM CARE | Welfare Benefit Premiums Paid to Carrier | USD $55,673 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,392 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 125803 |
Policy instance | 7 |
Insurance contract or identification number | 125803 | Number of Individuals Covered | 66 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $3,636 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LEGAL | Welfare Benefit Premiums Paid to Carrier | USD $12,234 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,636 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 48385 |
Policy instance | 8 |
Insurance contract or identification number | 48385 | Number of Individuals Covered | 101 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $29,787 | Total amount of fees paid to insurance company | USD $1,134 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Welfare Benefit Premiums Paid to Carrier | USD $757,059 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $29,787 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BONUS |
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CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 ) |
Policy contract number | 690 |
Policy instance | 3 |
Insurance contract or identification number | 690 | Number of Individuals Covered | 365 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $629 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $12,577 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $629 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | ETB151161 |
Policy instance | 4 |
Insurance contract or identification number | ETB151161 | Number of Individuals Covered | 333 | Insurance policy start date | 2018-07-01 | Insurance policy end date | 2019-06-30 | Total amount of commissions paid to insurance broker | USD $181 | Total amount of fees paid to insurance company | USD $33 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $1,204 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $181 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BONUS |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 05158A |
Policy instance | 5 |
Insurance contract or identification number | 05158A | Number of Individuals Covered | 1 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,248 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $12,478 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $1,248 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 537536 |
Policy instance | 6 |
Insurance contract or identification number | 537536 | Number of Individuals Covered | 408 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $9,114 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LONG TERM CARE | Welfare Benefit Premiums Paid to Carrier | USD $60,393 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,114 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 125803 |
Policy instance | 7 |
Insurance contract or identification number | 125803 | Number of Individuals Covered | 74 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $3,880 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LEGAL | Welfare Benefit Premiums Paid to Carrier | USD $11,359 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,767 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 4 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | ETB151161 |
Policy instance | 8 |
Insurance contract or identification number | ETB151161 | Number of Individuals Covered | 333 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
Policy contract number | 154708 |
Policy instance | 9 |
Insurance contract or identification number | 154708 | Number of Individuals Covered | 364 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $63,587 | Total amount of fees paid to insurance company | USD $4,927 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $51,922 | Amount paid for insurance broker fees | 4927 | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 48385 |
Policy instance | 10 |
Insurance contract or identification number | 48385 | Number of Individuals Covered | 101 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $26,637 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Welfare Benefit Premiums Paid to Carrier | USD $605,150 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $26,637 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10117291001 |
Policy instance | 2 |
Insurance contract or identification number | 10117291001 | Number of Individuals Covered | 904 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $3,676 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $73,175 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,676 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 915712 |
Policy instance | 1 |
Insurance contract or identification number | 915712 | Number of Individuals Covered | 777 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $215,104 | Total amount of fees paid to insurance company | USD $10,000 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $5,146,238 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $205,246 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BONUS |
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STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
Policy contract number | 154708 |
Policy instance | 9 |
Insurance contract or identification number | 154708 | Number of Individuals Covered | 392 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $74,954 | Total amount of fees paid to insurance company | USD $14,156 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $74,954 | Amount paid for insurance broker fees | 5739 | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | Insurance broker organization code? | 3 |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 281294 |
Policy instance | 1 |
Insurance contract or identification number | 281294 | Number of Individuals Covered | 876 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $309,033 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $5,597,956 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $197,767 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 ) |
Policy contract number | 690 |
Policy instance | 2 |
Insurance contract or identification number | 690 | Number of Individuals Covered | 384 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $714 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $14,272 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $714 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | ETB151161 |
Policy instance | 3 |
Insurance contract or identification number | ETB151161 | Number of Individuals Covered | 387 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $181 | Total amount of fees paid to insurance company | USD $3 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $1,204 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $181 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BONUS |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 05158A |
Policy instance | 4 |
Insurance contract or identification number | 05158A | Number of Individuals Covered | 1 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $2,496 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $24,955 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $2,496 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 537536 |
Policy instance | 5 |
Insurance contract or identification number | 537536 | Number of Individuals Covered | 390 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $10,236 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LONG TERM CARE | Welfare Benefit Premiums Paid to Carrier | USD $68,289 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,236 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 125803 |
Policy instance | 6 |
Insurance contract or identification number | 125803 | Number of Individuals Covered | 47 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $3,796 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LEGAL | Welfare Benefit Premiums Paid to Carrier | USD $8,884 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,756 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 48385 |
Policy instance | 7 |
Insurance contract or identification number | 48385 | Number of Individuals Covered | 103 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $32,070 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Welfare Benefit Premiums Paid to Carrier | USD $659,429 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $32,070 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10117291001 |
Policy instance | 8 |
Insurance contract or identification number | 10117291001 | Number of Individuals Covered | 983 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $4,780 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Welfare Benefit Premiums Paid to Carrier | USD $75,725 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,780 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 1011729 |
Policy instance | 2 |
Insurance contract or identification number | 1011729 | Number of Individuals Covered | 974 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $626 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $37,766 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $626 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | WELLS FARGO INSURANCE SERVICES USA |
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CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 ) |
Policy contract number | 690 |
Policy instance | 3 |
Insurance contract or identification number | 690 | Number of Individuals Covered | 410 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $383 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $7,654 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $383 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | ETB-151161 |
Policy instance | 4 |
Insurance contract or identification number | ETB-151161 | Number of Individuals Covered | 402 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $120 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $803 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $120 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 05158A |
Policy instance | 5 |
Insurance contract or identification number | 05158A | Number of Individuals Covered | 1 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $4,991 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $49,910 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $4,991 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | WELLS FARGO INSURANCE SERVICES USA |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 537536 |
Policy instance | 6 |
Insurance contract or identification number | 537536 | Number of Individuals Covered | 385 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $4,768 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LONG TERM CARE | Welfare Benefit Premiums Paid to Carrier | USD $31,856 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,768 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 125803 |
Policy instance | 7 |
Insurance contract or identification number | 125803 | Number of Individuals Covered | 47 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $1,863 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LEGAL | Welfare Benefit Premiums Paid to Carrier | USD $3,716 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,840 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 4 | Insurance broker name | KYLE M STAFFORD |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 48385 |
Policy instance | 8 |
Insurance contract or identification number | 48385 | Number of Individuals Covered | 92 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $2,330 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Welfare Benefit Premiums Paid to Carrier | USD $267,124 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,330 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
Policy contract number | 154708 |
Policy instance | 9 |
Insurance contract or identification number | 154708 | Number of Individuals Covered | 400 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $30,406 | Total amount of fees paid to insurance company | USD $10,135 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $30,406 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker name | PLANSOURCE BENEFITS ADMIN INC |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 281294 |
Policy instance | 1 |
Insurance contract or identification number | 281294 | Number of Individuals Covered | 893 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $144,336 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,892,603 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $144,336 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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