401k Plan data: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN plan

DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN
Plan identification number	501

DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN Benefits

401k Plan Type

Welfare Benefit

Plan Features/Benefits

Health (other than dental or vision)
Life insurance
Dental
Vision
Temporary disability (accident and sickness)
Long-term disability cover
Death benefits (include travel accident but not life insurance)
Other welfare benefit cover
Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

DELTA SOLUTIONS AND STRATEGIES LLC has sponsored the creation of one or more 401k plans.

Company Name: DELTA SOLUTIONS AND STRATEGIES LLC

Employer identification number (EIN): 841554002

NAIC Classification: 541600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 DEBBIE LEACH 2023-08-02
501 2021-01-01 DEBBIE LEACH 2022-09-21
501 2021-01-01 DEBBIE LEACH 2022-10-24
501 2021-01-01 DEBBIE LEACH 2023-08-03
501 2020-01-01 DEBBIE LEACH 2021-05-20
501 2020-01-01 DEBBIE LEACH 2022-10-18
501 2012-01-01 GARY L BAIN
501 2011-08-01 SHARLENE YABE

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	DEBBIE LEACH	2023-08-02
501	2021-01-01	DEBBIE LEACH	2022-09-21
501	2021-01-01	DEBBIE LEACH	2022-10-24
501	2021-01-01	DEBBIE LEACH	2023-08-03
501	2020-01-01	DEBBIE LEACH	2021-05-20
501	2020-01-01	DEBBIE LEACH	2022-10-18
501	2012-01-01	GARY L BAIN
501	2011-08-01	SHARLENE YABE

Plan Statistics for DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 214
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 286
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 286
Number of employers contributing to the scheme 2022-01-01 0
2021: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 166
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 214
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 214
Number of employers contributing to the scheme 2021-01-01 0
2020: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 111
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 166
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 166
Number of employers contributing to the scheme 2020-01-01 0
2012: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 74
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 74
2011: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-08-01 117
Total number of active participants reported on line 7a of the Form 5500 2011-08-01 113
Number of retired or separated participants receiving benefits 2011-08-01 0
Number of other retired or separated participants entitled to future benefits 2011-08-01 0
Total of all active and inactive participants 2011-08-01 113

Measure	Date	Value
2022: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	214
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	286
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	286
Number of employers contributing to the scheme	2022-01-01	0
2021: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	166
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	214
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	214
Number of employers contributing to the scheme	2021-01-01	0
2020: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	111
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	166
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	166
Number of employers contributing to the scheme	2020-01-01	0
2012: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	74
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	74
2011: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-08-01	117
Total number of active participants reported on line 7a of the Form 5500	2011-08-01	113
Number of retired or separated participants receiving benefits	2011-08-01	0
Number of other retired or separated participants entitled to future benefits	2011-08-01	0
Total of all active and inactive participants	2011-08-01	113

Form 5500 Responses for DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN

2022: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	Yes
2020-01-01	Plan is a collectively bargained plan	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: DELTA SOLUTIONS AND STRATEGIES, LLC EMPLOYEE BENEFITS PLAN 2011 form 5500 responses
2011-08-01	Type of plan entity	Single employer plan
2011-08-01	First time form 5500 has been submitted	Yes
2011-08-01	Submission has been amended	No
2011-08-01	This submission is the final filing	No
2011-08-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2011-08-01	Plan is a collectively bargained plan	No
2011-08-01	Plan funding arrangement – Insurance	Yes
2011-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-08-01	Plan benefit arrangement – Insurance	Yes
2011-08-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

MULTINATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 72087 )

Policy contract number

40-5135-0

Policy instance

Insurance contract or identification number	40-5135-0
Number of Individuals Covered	7
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $3,469
Total amount of fees paid to insurance company	USD $0
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, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $17,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,238
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

96772201001

Policy instance

Insurance contract or identification number	96772201001
Number of Individuals Covered	430
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,569
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,615
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

592815

Policy instance

Insurance contract or identification number	592815
Number of Individuals Covered	196
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,981
Total amount of fees paid to insurance company	USD $216
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $168,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,981
Amount paid for insurance broker fees	216
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

122756

Policy instance

Insurance contract or identification number	122756
Number of Individuals Covered	243
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,316
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $42,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,316
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CENTURA HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

DELTA

Policy instance

Insurance contract or identification number	DELTA
Number of Individuals Covered	86
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $4,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

16995

Policy instance

Insurance contract or identification number	16995
Number of Individuals Covered	7
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,302
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,302
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )

Policy contract number

L01557

Policy instance

Insurance contract or identification number	L01557
Number of Individuals Covered	208
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $38,864
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,371,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,864
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HUMANA INSURANCE OF PUERTO RICO (National Association of Insurance Commissioners NAIC id number: 84603 )

Policy contract number

211670

Policy instance

Insurance contract or identification number	211670
Number of Individuals Covered	7
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,915
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,915
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

NEW BENEFITS LTD TELADOC HEALTH ADVOCATE AND UNITED HEALTHCARE GLO (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

HUB1002CE

Policy instance

Insurance contract or identification number	HUB1002CE
Number of Individuals Covered	19
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $533
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TELEHEALTH
Welfare Benefit Premiums Paid to Carrier	USD $2,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $533
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

11855

Policy instance

Insurance contract or identification number	11855
Number of Individuals Covered	48
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,425
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $17,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,371
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AVB9

Policy instance

Insurance contract or identification number	GLUG0AVB9
Number of Individuals Covered	286
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $15,252
Total amount of fees paid to insurance company	USD $7,937
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 $152,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,252
Amount paid for insurance broker fees	7937
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

CENTURA HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

DELTA

Policy instance

Insurance contract or identification number	DELTA
Number of Individuals Covered	86
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $4,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

16995

Policy instance

Insurance contract or identification number	16995
Number of Individuals Covered	7
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,274
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,274
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )

Policy contract number

L01557

Policy instance

Insurance contract or identification number	L01557
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 $29,288
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,042,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,288
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HUMANA INSURANCE OF PUERTO RICO (National Association of Insurance Commissioners NAIC id number: 84603 )

Policy contract number

211670

Policy instance

Insurance contract or identification number	211670
Number of Individuals Covered	7
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,150
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,150
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

11855

Policy instance

Insurance contract or identification number	11855
Number of Individuals Covered	38
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,044
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $6,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,861
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AVB9

Policy instance

Insurance contract or identification number	GLUG0AVB9
Number of Individuals Covered	214
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,339
Total amount of fees paid to insurance company	USD $4,121
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 $113,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,339
Amount paid for insurance broker fees	4121
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MULTINATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 72087 )

Policy contract number

40-5135-0

Policy instance

Insurance contract or identification number	40-5135-0
Number of Individuals Covered	7
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $2,940
Total amount of fees paid to insurance company	USD $0
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, CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,940
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

122756 0001

Policy instance

Insurance contract or identification number	122756 0001
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 $5,535
Total amount of fees paid to insurance company	USD $0
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	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $36,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,535
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

16995

Policy instance

Insurance contract or identification number	16995
Number of Individuals Covered	7
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,274
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,274
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AVB9

Policy instance

Insurance contract or identification number	GLUG0AVB9
Number of Individuals Covered	214
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,339
Total amount of fees paid to insurance company	USD $4,121
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 $113,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,339
Amount paid for insurance broker fees	4121
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MULTINATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 72087 )

Policy contract number

40-5135-0

Policy instance

Insurance contract or identification number	40-5135-0
Number of Individuals Covered	7
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $2,940
Total amount of fees paid to insurance company	USD $0
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, CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,940
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

HUB1002CE

Policy instance

Insurance contract or identification number	HUB1002CE
Number of Individuals Covered	214
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TELEHEALTH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HUMANA INSURANCE OF PUERTO RICO (National Association of Insurance Commissioners NAIC id number: 84603 )

Policy contract number

211670

Policy instance

Insurance contract or identification number	211670
Number of Individuals Covered	7
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,150
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,150
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )

Policy contract number

L01557

Policy instance

Insurance contract or identification number	L01557
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 $29,288
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,042,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,288
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

11855

Policy instance

Insurance contract or identification number	11855
Number of Individuals Covered	38
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,044
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $6,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,861
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CENTURA HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

DELTA

Policy instance

Insurance contract or identification number	DELTA
Number of Individuals Covered	86
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $4,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

HUB1002CE

Policy instance

Insurance contract or identification number	HUB1002CE
Number of Individuals Covered	214
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TELEHEALTH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

122756

Policy instance

Insurance contract or identification number	122756
Number of Individuals Covered	214
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

592815

Policy instance

Insurance contract or identification number	592815
Number of Individuals Covered	145
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,035
Total amount of fees paid to insurance company	USD $202
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $129,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,035
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

96772201001

Policy instance

Insurance contract or identification number	96772201001
Number of Individuals Covered	310
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,787
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,787
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

122756 0001

Policy instance

Insurance contract or identification number	122756 0001
Number of Individuals Covered	133
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,431
Total amount of fees paid to insurance company	USD $0
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	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $28,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,431
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AVB9

Policy instance

Insurance contract or identification number	GLUG0AVB9
Number of Individuals Covered	166
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,067
Total amount of fees paid to insurance company	USD $953
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $20,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,067
Amount paid for insurance broker fees	953
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MULTINATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 72087 )

Policy contract number

40-5135

Policy instance

Insurance contract or identification number	40-5135
Number of Individuals Covered	7
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $3,137
Total amount of fees paid to insurance company	USD $0
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, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $15,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,137
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

16995

Policy instance

Insurance contract or identification number	16995
Number of Individuals Covered	6
Insurance policy start date	2020-09-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $281
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $281
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

11855

Policy instance

Insurance contract or identification number	11855
Number of Individuals Covered	38
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $191
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $2,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $149
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

HUB1002CE

Policy instance

Insurance contract or identification number	HUB1002CE
Number of Individuals Covered	166
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TELEHEALTH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

CENTURA HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance contract or identification number	00
Number of Individuals Covered	86
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $4,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

96772201001

Policy instance

Insurance contract or identification number	96772201001
Number of Individuals Covered	330
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,387
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,987
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

592815

Policy instance

Insurance contract or identification number	592815
Number of Individuals Covered	103
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $15,306
Total amount of fees paid to insurance company	USD $1,487
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $511,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,306
Amount paid for insurance broker fees	1487
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

HUMANA INSURANCE OF PUERTO RICO (National Association of Insurance Commissioners NAIC id number: 84603 )

Policy contract number

211670

Policy instance

Insurance contract or identification number	211670
Number of Individuals Covered	18
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,814
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,814
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AVB9

Policy instance

Insurance contract or identification number	GLUG0AVB9
Number of Individuals Covered	166
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,869
Total amount of fees paid to insurance company	USD $3,014
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 $68,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,869
Amount paid for insurance broker fees	3014
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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Company Name:	DELTA SOLUTIONS AND STRATEGIES LLC
Employer identification number (EIN):	841554002
NAIC Classification:	541600