AMBARELLA CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan AMBARELLA CORPORATION HEALTH & WELFARE BENEFIT PLAN
401k plan membership statisitcs for AMBARELLA CORPORATION HEALTH & WELFARE BENEFIT PLAN
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 948706 |
Policy instance | 6 |
Insurance contract or identification number | 948706 | Number of Individuals Covered | 267 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $45,134 | Total amount of fees paid to insurance company | USD $16,690 | Dental Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $611,014 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $45,134 | Amount paid for insurance broker fees | 16690 | Additional information about fees paid to insurance broker | BONUS | 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 | 278194 |
Policy instance | 1 |
Insurance contract or identification number | 278194 | Number of Individuals Covered | 370 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $126,273 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $3,066,142 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $126,273 | 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 | 604254 |
Policy instance | 2 |
Insurance contract or identification number | 604254 | Number of Individuals Covered | 172 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $46,584 | Total amount of fees paid to insurance company | USD $942 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $862,768 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $46,584 | Amount paid for insurance broker fees | 942 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
|
LEGAL CLUB OF AMERICA (National Association of Insurance Commissioners NAIC id number: 54111 ) |
Policy contract number | AMBARELLA |
Policy instance | 3 |
Insurance contract or identification number | AMBARELLA | Number of Individuals Covered | 29 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $1,010 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LEGAL | Welfare Benefit Premiums Paid to Carrier | USD $25,330 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $946 | Amount paid for insurance broker fees | 0 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
|
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
Policy contract number | 9907-69-23 |
Policy instance | 4 |
Insurance contract or identification number | 9907-69-23 | Number of Individuals Covered | 267 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $922 | Total amount of fees paid to insurance company | USD $92 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $4,608 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $922 | Amount paid for insurance broker fees | 92 | Additional information about fees paid to insurance broker | CONTINGENT COMMISSION | Insurance broker organization code? | 3 |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30043523 |
Policy instance | 5 |
Insurance contract or identification number | 30043523 | Number of Individuals Covered | 237 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $2,095 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $65,814 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,095 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 278194 |
Policy instance | 1 |
Insurance contract or identification number | 278194 | Number of Individuals Covered | 256 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $78,274 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,194,445 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $78,274 | 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 | 604254 |
Policy instance | 2 |
Insurance contract or identification number | 604254 | Number of Individuals Covered | 176 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $47,758 | Total amount of fees paid to insurance company | USD $448 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $880,153 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $47,758 | Amount paid for insurance broker fees | 448 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | AMBARELLA |
Policy instance | 3 |
Insurance contract or identification number | AMBARELLA | Number of Individuals Covered | 28 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $1,266 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LEGAL | Welfare Benefit Premiums Paid to Carrier | USD $4,580 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $1,116 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
Policy contract number | 9907-69-23 |
Policy instance | 4 |
Insurance contract or identification number | 9907-69-23 | Number of Individuals Covered | 199 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $922 | Total amount of fees paid to insurance company | USD $230 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $4,608 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $922 | Amount paid for insurance broker fees | 230 | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | Insurance broker organization code? | 3 |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30043523 |
Policy instance | 5 |
Insurance contract or identification number | 30043523 | Number of Individuals Covered | 183 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $1,985 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $52,175 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,985 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
Policy contract number | 474422 |
Policy instance | 6 |
Insurance contract or identification number | 474422 | Number of Individuals Covered | 32 | Insurance policy start date | 2021-01-02 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $714 | Total amount of fees paid to insurance company | USD $131 | Other welfare benefits provided | CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $7,425 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $714 | Amount paid for insurance broker fees | 131 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 ) |
Policy contract number | 474421 |
Policy instance | 7 |
Insurance contract or identification number | 474421 | Number of Individuals Covered | 189 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $15,379 | Total amount of fees paid to insurance company | USD $5,383 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $307,584 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $15,379 | Amount paid for insurance broker fees | 5383 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | 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 | 952692 |
Policy instance | 8 |
Insurance contract or identification number | 952692 | Number of Individuals Covered | 199 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $19,597 | Total amount of fees paid to insurance company | USD $2,886 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $178,032 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $19,597 | Amount paid for insurance broker fees | 2886 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
|
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 278194 |
Policy instance | 1 |
Insurance contract or identification number | 278194 | Number of Individuals Covered | 227 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $75,522 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,593,784 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $75,522 | 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 | 604254 |
Policy instance | 2 |
Insurance contract or identification number | 604254 | Number of Individuals Covered | 165 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $44,851 | Total amount of fees paid to insurance company | USD $1,956 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $975,147 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $44,851 | Amount paid for insurance broker fees | 1956 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30043523 |
Policy instance | 3 |
Insurance contract or identification number | 30043523 | Number of Individuals Covered | 162 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $1,656 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $44,521 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,656 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | AMBARELLA |
Policy instance | 4 |
Insurance contract or identification number | AMBARELLA | Number of Individuals Covered | 22 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $1,015 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LEGAL | Welfare Benefit Premiums Paid to Carrier | USD $3,802 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $844 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
Policy contract number | 9907-69-23 |
Policy instance | 5 |
Insurance contract or identification number | 9907-69-23 | Number of Individuals Covered | 185 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $1,839 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $7,357 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $1,839 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 ) |
Policy contract number | 474421 |
Policy instance | 6 |
Insurance contract or identification number | 474421 | Number of Individuals Covered | 164 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $16,814 | Total amount of fees paid to insurance company | USD $6,396 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $336,271 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $16,814 | Amount paid for insurance broker fees | 6396 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
Policy contract number | 474422 |
Policy instance | 7 |
Insurance contract or identification number | 474422 | Number of Individuals Covered | 24 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $1,013 | Total amount of fees paid to insurance company | USD $82 | Other welfare benefits provided | CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $4,083 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,013 | Amount paid for insurance broker fees | 82 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | 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 | 952692 |
Policy instance | 8 |
Insurance contract or identification number | 952692 | Number of Individuals Covered | 183 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $21,149 | Total amount of fees paid to insurance company | USD $1,159 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $153,281 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $21,149 | Amount paid for insurance broker fees | 1159 | Additional information about fees paid to insurance broker | ADDITIONAL 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 | 604254 |
Policy instance | 2 |
Insurance contract or identification number | 604254 | Number of Individuals Covered | 165 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $41,916 | Total amount of fees paid to insurance company | USD $2,548 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $774,632 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $41,916 | Amount paid for insurance broker fees | 2548 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5912666 |
Policy instance | 3 |
Insurance contract or identification number | 5912666 | Number of Individuals Covered | 589 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $7,007 | Total amount of fees paid to insurance company | USD $2,843 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $345,691 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,007 | Amount paid for insurance broker fees | 2843 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30043523 |
Policy instance | 4 |
Insurance contract or identification number | 30043523 | Number of Individuals Covered | 161 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,911 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $44,497 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,911 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
Policy contract number | 22332 |
Policy instance | 5 |
Insurance contract or identification number | 22332 | Number of Individuals Covered | 29 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,126 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $11,129 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,126 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | AMBARELLA |
Policy instance | 6 |
Insurance contract or identification number | AMBARELLA | Number of Individuals Covered | 17 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,214 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LEGAL | Welfare Benefit Premiums Paid to Carrier | USD $3,906 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $948 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
Policy contract number | 9907-69-23 |
Policy instance | 7 |
Insurance contract or identification number | 9907-69-23 | Number of Individuals Covered | 178 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,839 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $7,357 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $1,839 | Amount paid for insurance broker fees | 0 | 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 | 278194 |
Policy instance | 1 |
Insurance contract or identification number | 278194 | Number of Individuals Covered | 229 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $68,040 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,691,105 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $68,040 | 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 | 952692 |
Policy instance | 8 |
Insurance contract or identification number | 952692 | Number of Individuals Covered | 178 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $12,629 | Total amount of fees paid to insurance company | USD $947 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $137,059 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,629 | Amount paid for insurance broker fees | 947 | Additional information about fees paid to insurance broker | ADDITIONAL 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 | 278194 |
Policy instance | 1 |
Insurance contract or identification number | 278194 | Number of Individuals Covered | 235 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $58,923 | Total amount of fees paid to insurance company | USD $8 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,753,136 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $37,247 | Amount paid for insurance broker fees | 6 | Additional information about fees paid to insurance broker | FEES | 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 | 604254 |
Policy instance | 2 |
Insurance contract or identification number | 604254 | Number of Individuals Covered | 157 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $43,063 | Total amount of fees paid to insurance company | USD $2,716 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $857,893 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $43,063 | Amount paid for insurance broker fees | 2716 | Additional information about fees paid to insurance broker | BONUS | 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 | 952692 |
Policy instance | 8 |
Insurance contract or identification number | 952692 | Number of Individuals Covered | 170 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $12,318 | Total amount of fees paid to insurance company | USD $2,463 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $123,177 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,318 | Amount paid for insurance broker fees | 2463 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05912666 |
Policy instance | 3 |
Insurance contract or identification number | KM05912666 | Number of Individuals Covered | 584 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $6,867 | Total amount of fees paid to insurance company | USD $5,113 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $334,250 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,867 | Amount paid for insurance broker fees | 5113 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30043523 |
Policy instance | 4 |
Insurance contract or identification number | 30043523 | Number of Individuals Covered | 155 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $1,693 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $42,466 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $1,693 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
Policy contract number | 22332 |
Policy instance | 5 |
Insurance contract or identification number | 22332 | Number of Individuals Covered | 29 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $934 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $9,301 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $831 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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LEGAL CLUB OF AMERICA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | AMBARELLA |
Policy instance | 6 |
Insurance contract or identification number | AMBARELLA | Number of Individuals Covered | 19 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $1,292 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LEGAL | Welfare Benefit Premiums Paid to Carrier | USD $3,724 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $925 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
Policy contract number | 9907-69-23 |
Policy instance | 7 |
Insurance contract or identification number | 9907-69-23 | Number of Individuals Covered | 168 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $5,518 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $22,071 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $5,518 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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LEGAL CLUB OF AMERICA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | AMBARELLA |
Policy instance | 1 |
Insurance contract or identification number | AMBARELLA | Number of Individuals Covered | 13 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $1,298 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | LEGAL | Welfare Benefit Premiums Paid to Carrier | USD $3,612 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $1,298 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | ABD INS. AND FINANCIAL SVCS., INC. |
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FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
Policy contract number | 99076923 |
Policy instance | 2 |
Insurance contract or identification number | 99076923 | Number of Individuals Covered | 150 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $1,278 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $8,523 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $1,278 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | ABD INS. AND FINANCIAL SVCS., INC. |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 604254 |
Policy instance | 3 |
Insurance contract or identification number | 604254 | Number of Individuals Covered | 154 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $35,476 | Total amount of fees paid to insurance company | USD $315 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $729,010 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $35,476 | Amount paid for insurance broker fees | 315 | Additional information about fees paid to insurance broker | BONUS NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | ABD INS. AND FINANCIAL SVCS., INC. |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05912666 |
Policy instance | 4 |
Insurance contract or identification number | KM05912666 | Number of Individuals Covered | 559 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $6,591 | Total amount of fees paid to insurance company | USD $5,783 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $302,018 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,591 | Amount paid for insurance broker fees | 5783 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | ABD INS. AND FINANCIAL SVCS., INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30043523 |
Policy instance | 5 |
Insurance contract or identification number | 30043523 | Number of Individuals Covered | 141 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $1,596 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $38,233 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,596 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | ABD INS. AND FINANCIAL SVCS., INC. |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 278194 |
Policy instance | 6 |
Insurance contract or identification number | 278194 | Number of Individuals Covered | 230 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $65,035 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $1,398,737 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $65,035 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | ABD INS. AND FINANCIAL SVCS., INC. |
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CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
Policy contract number | 22332 |
Policy instance | 7 |
Insurance contract or identification number | 22332 | Number of Individuals Covered | 25 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $2,506 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $10,278 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,859 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | ABD INS. AND FINANCIAL SVCS., INC. |
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ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
Policy contract number | 278194 |
Policy instance | 1 |
Insurance contract or identification number | 278194 | Number of Individuals Covered | 207 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $48,684 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,161,826 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $48,684 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
Policy contract number | 99076923 |
Policy instance | 2 |
Insurance contract or identification number | 99076923 | Number of Individuals Covered | 137 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $2,131 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $8,523 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,131 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 604254 |
Policy instance | 3 |
Insurance contract or identification number | 604254 | Number of Individuals Covered | 129 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $32,202 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $656,836 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $32,202 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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LEGAL CLUB OF AMERICA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00000 |
Policy instance | 4 |
Insurance contract or identification number | 00000 | Number of Individuals Covered | 10 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $749 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | LEGAL | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,498 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $749 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05912666 |
Policy instance | 5 |
Insurance contract or identification number | KM05912666 | Number of Individuals Covered | 525 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $5,936 | Total amount of fees paid to insurance company | USD $4,916 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $249,394 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,936 | Amount paid for insurance broker fees | 38 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 403115 |
Policy instance | 6 |
Insurance contract or identification number | 403115 | Number of Individuals Covered | 135 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-06-30 | Total amount of commissions paid to insurance broker | USD $5,732 | Total amount of fees paid to insurance company | USD $626 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $42,431 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,732 | Amount paid for insurance broker fees | 626 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 403119 |
Policy instance | 7 |
Insurance contract or identification number | 403119 | Number of Individuals Covered | 76 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-06-30 | Total amount of commissions paid to insurance broker | USD $3,050 | Total amount of fees paid to insurance company | USD $254 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $16,851 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,050 | Amount paid for insurance broker fees | 254 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30043523 |
Policy instance | 8 |
Insurance contract or identification number | 30043523 | Number of Individuals Covered | 123 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $1,476 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $33,051 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,476 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 604254 |
Policy instance | 2 |
Insurance contract or identification number | 604254 | Number of Individuals Covered | 98 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $15,748 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $567,429 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $15,748 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 403115 |
Policy instance | 3 |
Insurance contract or identification number | 403115 | Number of Individuals Covered | 122 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $7,327 | Total amount of fees paid to insurance company | USD $1,133 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $90,122 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,040 | Amount paid for insurance broker fees | 1133 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | CASSIDY E. O'HARA |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 403119 |
Policy instance | 4 |
Insurance contract or identification number | 403119 | Number of Individuals Covered | 76 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $6,220 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | LIFESTYLE ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $42,946 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,944 | Amount paid for insurance broker fees | 491 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | CASSIDY E. O'HARA |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30043523 |
Policy instance | 5 |
Insurance contract or identification number | 30043523 | Number of Individuals Covered | 108 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $2,127 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $44,785 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,138 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05912666 |
Policy instance | 6 |
Insurance contract or identification number | KM05912666 | Number of Individuals Covered | 466 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $4,526 | Total amount of fees paid to insurance company | USD $1,838 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $178,102 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,592 | Amount paid for insurance broker fees | 1838 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | CASSIDY O'HARA |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 278194 |
Policy instance | 1 |
Insurance contract or identification number | 278194 | Number of Individuals Covered | 194 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $34,679 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $949,234 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $19,117 | Insurance broker organization code? | 3 | Insurance broker name | RON FILICE ENTERPRISES INC. |
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