CRIMSON WINE GROUP, LTD has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CRIMSON WINE GROUP HEALTH AND WELFARE PLANS
| Measure | Date | Value |
|---|
| 2015: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-11-01 | 167 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-11-01 | 173 |
| Number of retired or separated participants receiving benefits | 2015-11-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2015-11-01 | 0 |
| Total of all active and inactive participants | 2015-11-01 | 176 |
| 2014: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-11-01 | 147 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-11-01 | 166 |
| Number of retired or separated participants receiving benefits | 2014-11-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2014-11-01 | 0 |
| Total of all active and inactive participants | 2014-11-01 | 167 |
| 2013: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-11-01 | 150 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-11-01 | 147 |
| Number of retired or separated participants receiving benefits | 2013-11-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2013-11-01 | 0 |
| Total of all active and inactive participants | 2013-11-01 | 149 |
| 2012: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-11-01 | 151 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-11-01 | 146 |
| Number of retired or separated participants receiving benefits | 2012-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-11-01 | 4 |
| Total of all active and inactive participants | 2012-11-01 | 150 |
| 2011: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-11-01 | 150 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-11-01 | 148 |
| Number of retired or separated participants receiving benefits | 2011-11-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2011-11-01 | 0 |
| Total of all active and inactive participants | 2011-11-01 | 151 |
| 2015: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2015 form 5500 responses |
|---|
| 2015-11-01 | Type of plan entity | Single employer plan |
| 2015-11-01 | Submission has been amended | No |
| 2015-11-01 | This submission is the final filing | No |
| 2015-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-11-01 | Plan is a collectively bargained plan | No |
| 2015-11-01 | Plan funding arrangement – Insurance | Yes |
| 2015-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2014 form 5500 responses |
|---|
| 2014-11-01 | Type of plan entity | Single employer plan |
| 2014-11-01 | Submission has been amended | No |
| 2014-11-01 | This submission is the final filing | No |
| 2014-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-11-01 | Plan is a collectively bargained plan | No |
| 2014-11-01 | Plan funding arrangement – Insurance | Yes |
| 2014-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2013 form 5500 responses |
|---|
| 2013-11-01 | Type of plan entity | Single employer plan |
| 2013-11-01 | Submission has been amended | No |
| 2013-11-01 | This submission is the final filing | No |
| 2013-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-11-01 | Plan is a collectively bargained plan | No |
| 2013-11-01 | Plan funding arrangement – Insurance | Yes |
| 2013-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2012 form 5500 responses |
|---|
| 2012-11-01 | Type of plan entity | Single employer plan |
| 2012-11-01 | Submission has been amended | No |
| 2012-11-01 | This submission is the final filing | No |
| 2012-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-11-01 | Plan is a collectively bargained plan | No |
| 2012-11-01 | Plan funding arrangement – Insurance | Yes |
| 2012-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2011 form 5500 responses |
|---|
| 2011-11-01 | Type of plan entity | Single employer plan |
| 2011-11-01 | First time form 5500 has been submitted | Yes |
| 2011-11-01 | Submission has been amended | No |
| 2011-11-01 | This submission is the final filing | No |
| 2011-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-11-01 | Plan is a collectively bargained plan | No |
| 2011-11-01 | Plan funding arrangement – Insurance | Yes |
| 2011-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 659295 |
| Policy instance | 3 |
| Insurance contract or identification number | 659295 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $11,036 | | 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 | 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 $157,653 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $11,036 | | Insurance broker organization code? | 3 | | Insurance broker name | WOODRUFF-SAWYER AND COMPANY |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30042762 |
| Policy instance | 4 |
| Insurance contract or identification number | 30042762 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $1,029 | | 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 $17,834 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,029 | | Insurance broker organization code? | 3 | | Insurance broker name | WOODRUFF-SAWYER AND COMPANY |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C23742 |
| Policy instance | 2 |
| Insurance contract or identification number | C23742 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $51,648 | | Total amount of fees paid to insurance company | USD $22,720 | | 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 $1,005,719 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $51,648 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 22720 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | WARNER PACIFIC INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603743 |
| Policy instance | 1 |
| Insurance contract or identification number | 603743 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $24,282 | | Total amount of fees paid to insurance company | USD $671 | | 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 $484,288 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,282 | | Amount paid for insurance broker fees | 671 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | WOODRUFF-SAWYER AND COMPANY |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30042762 |
| Policy instance | 4 |
| Insurance contract or identification number | 30042762 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $957 | | 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 $15,827 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $957 | | Insurance broker organization code? | 3 | | Insurance broker name | WOODRUFF-SAWYER AND COMPANY |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603743 |
| Policy instance | 1 |
| Insurance contract or identification number | 603743 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $20,826 | | Total amount of fees paid to insurance company | USD $1,574 | | 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 $459,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,826 | | Amount paid for insurance broker fees | 1574 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | WOODRUFF-SAWYER AND COMPANY |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C23742 |
| Policy instance | 2 |
| Insurance contract or identification number | C23742 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $41,474 | | Total amount of fees paid to insurance company | USD $18,335 | | 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 $583,625 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,474 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 18335 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | WARNER PACIFIC INSURANCE SERVICES |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 659295 |
| Policy instance | 3 |
| Insurance contract or identification number | 659295 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $8,904 | | 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 | 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 $127,199 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,904 | | Insurance broker organization code? | 3 | | Insurance broker name | WOODRUFF-SAWYER AND COMPANY |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603743 |
| Policy instance | 1 |
| Insurance contract or identification number | 603743 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $17,468 | | Total amount of fees paid to insurance company | USD $3,960 | | 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 $316,488 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,468 | | Amount paid for insurance broker fees | 3960 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | WOODRUFF-SAWYER AND COMPANY |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 659295 |
| Policy instance | 4 |
| Insurance contract or identification number | 659295 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $8,157 | | 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 | 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 $116,534 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,157 | | Insurance broker organization code? | 3 | | Insurance broker name | WOODRUFF-SAWYER AND COMPANY |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 153883 |
| Policy instance | 3 |
| Insurance contract or identification number | 153883 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $7,785 | | Total amount of fees paid to insurance company | USD $543 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,785 | | Amount paid for insurance broker fees | 543 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | WOODRUFF-SAWYER AND COMPANY |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C23742 |
| Policy instance | 2 |
| Insurance contract or identification number | C23742 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $42,775 | | Total amount of fees paid to insurance company | USD $21,474 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $819,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,775 | | Amount paid for insurance broker fees | 1241 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | WARNER PACIFIC INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603743 |
| Policy instance | 1 |
| Insurance contract or identification number | 603743 | | Number of Individuals Covered | 65 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $13,977 | | 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 $309,617 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C23742 |
| Policy instance | 2 |
| Insurance contract or identification number | C23742 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $39,985 | | Total amount of fees paid to insurance company | USD $15,840 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $763,831 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 153883 |
| Policy instance | 3 |
| Insurance contract or identification number | 153883 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $4,367 | | Total amount of fees paid to insurance company | USD $999 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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