VIGOR, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan VIGOR LLC HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2021: VIGOR LLC HEALTH AND WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-08-01 | 1,510 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-08-01 | 1,500 |
| Number of retired or separated participants receiving benefits | 2021-08-01 | 8 |
| Number of other retired or separated participants entitled to future benefits | 2021-08-01 | 0 |
| Total of all active and inactive participants | 2021-08-01 | 1,508 |
| Number of employers contributing to the scheme | 2021-08-01 | 0 |
| 2020: VIGOR LLC HEALTH AND WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-08-01 | 1,536 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-08-01 | 1,500 |
| Number of retired or separated participants receiving benefits | 2020-08-01 | 10 |
| Number of other retired or separated participants entitled to future benefits | 2020-08-01 | 0 |
| Total of all active and inactive participants | 2020-08-01 | 1,510 |
| Number of employers contributing to the scheme | 2020-08-01 | 0 |
| 2019: VIGOR LLC HEALTH AND WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-08-01 | 1,500 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-08-01 | 1,500 |
| Number of retired or separated participants receiving benefits | 2019-08-01 | 36 |
| Number of other retired or separated participants entitled to future benefits | 2019-08-01 | 0 |
| Total of all active and inactive participants | 2019-08-01 | 1,536 |
| Number of employers contributing to the scheme | 2019-08-01 | 0 |
| 2018: VIGOR LLC HEALTH AND WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-08-01 | 1,770 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-08-01 | 1,500 |
| Number of retired or separated participants receiving benefits | 2018-08-01 | 111 |
| Number of other retired or separated participants entitled to future benefits | 2018-08-01 | 17 |
| Total of all active and inactive participants | 2018-08-01 | 1,628 |
| Number of employers contributing to the scheme | 2018-08-01 | 0 |
| 2017: VIGOR LLC HEALTH AND WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-08-01 | 1,942 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-08-01 | 1,649 |
| Number of retired or separated participants receiving benefits | 2017-08-01 | 109 |
| Number of other retired or separated participants entitled to future benefits | 2017-08-01 | 12 |
| Total of all active and inactive participants | 2017-08-01 | 1,770 |
| Number of employers contributing to the scheme | 2017-08-01 | 0 |
| 2016: VIGOR LLC HEALTH AND WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-08-01 | 2,088 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-08-01 | 1,806 |
| Number of retired or separated participants receiving benefits | 2016-08-01 | 112 |
| Number of other retired or separated participants entitled to future benefits | 2016-08-01 | 24 |
| Total of all active and inactive participants | 2016-08-01 | 1,942 |
| 2015: VIGOR LLC HEALTH AND WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-08-01 | 1,461 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-08-01 | 1,943 |
| Number of retired or separated participants receiving benefits | 2015-08-01 | 124 |
| Number of other retired or separated participants entitled to future benefits | 2015-08-01 | 21 |
| Total of all active and inactive participants | 2015-08-01 | 2,088 |
| 2014: VIGOR LLC HEALTH AND WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-08-01 | 1,184 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-08-01 | 1,302 |
| Number of retired or separated participants receiving benefits | 2014-08-01 | 131 |
| Number of other retired or separated participants entitled to future benefits | 2014-08-01 | 28 |
| Total of all active and inactive participants | 2014-08-01 | 1,461 |
| 2013: VIGOR LLC HEALTH AND WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-08-01 | 1,064 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-08-01 | 987 |
| Number of retired or separated participants receiving benefits | 2013-08-01 | 155 |
| Number of other retired or separated participants entitled to future benefits | 2013-08-01 | 42 |
| Total of all active and inactive participants | 2013-08-01 | 1,184 |
| 2012: VIGOR LLC HEALTH AND WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-08-01 | 1,090 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-08-01 | 820 |
| Number of retired or separated participants receiving benefits | 2012-08-01 | 160 |
| Number of other retired or separated participants entitled to future benefits | 2012-08-01 | 84 |
| Total of all active and inactive participants | 2012-08-01 | 1,064 |
| 2011: VIGOR LLC HEALTH AND WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-08-01 | 453 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-08-01 | 1,074 |
| Number of retired or separated participants receiving benefits | 2011-08-01 | 15 |
| Number of other retired or separated participants entitled to future benefits | 2011-08-01 | 1 |
| Total of all active and inactive participants | 2011-08-01 | 1,090 |
| Total participants | 2011-08-01 | 1,090 |
| 2010: VIGOR LLC HEALTH AND WELFARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-08-01 | 441 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-08-01 | 422 |
| Number of retired or separated participants receiving benefits | 2010-08-01 | 30 |
| Number of other retired or separated participants entitled to future benefits | 2010-08-01 | 1 |
| Total of all active and inactive participants | 2010-08-01 | 453 |
| Total participants | 2010-08-01 | 453 |
| 2009: VIGOR LLC HEALTH AND WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-08-01 | 512 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-08-01 | 420 |
| Number of retired or separated participants receiving benefits | 2009-08-01 | 19 |
| Number of other retired or separated participants entitled to future benefits | 2009-08-01 | 2 |
| Total of all active and inactive participants | 2009-08-01 | 441 |
| Total participants | 2009-08-01 | 441 |
| 2021: VIGOR LLC HEALTH AND WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-08-01 | Type of plan entity | Single employer plan |
| 2021-08-01 | Plan funding arrangement – Insurance | Yes |
| 2021-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: VIGOR LLC HEALTH AND WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-08-01 | Type of plan entity | Single employer plan |
| 2020-08-01 | Plan funding arrangement – Insurance | Yes |
| 2020-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: VIGOR LLC HEALTH AND WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-08-01 | Type of plan entity | Single employer plan |
| 2019-08-01 | Plan funding arrangement – Insurance | Yes |
| 2019-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: VIGOR LLC HEALTH AND WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-08-01 | Type of plan entity | Single employer plan |
| 2018-08-01 | Plan funding arrangement – Insurance | Yes |
| 2018-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: VIGOR LLC HEALTH AND WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-08-01 | Type of plan entity | Single employer plan |
| 2017-08-01 | Plan funding arrangement – Insurance | Yes |
| 2017-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: VIGOR LLC HEALTH AND WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-08-01 | Type of plan entity | Single employer plan |
| 2016-08-01 | Submission has been amended | No |
| 2016-08-01 | This submission is the final filing | No |
| 2016-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-08-01 | Plan is a collectively bargained plan | No |
| 2016-08-01 | Plan funding arrangement – Insurance | Yes |
| 2016-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: VIGOR LLC HEALTH AND WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-08-01 | Type of plan entity | Single employer plan |
| 2015-08-01 | Submission has been amended | No |
| 2015-08-01 | This submission is the final filing | No |
| 2015-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-08-01 | Plan is a collectively bargained plan | No |
| 2015-08-01 | Plan funding arrangement – Insurance | Yes |
| 2015-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: VIGOR LLC HEALTH AND WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-08-01 | Type of plan entity | Single employer plan |
| 2014-08-01 | Submission has been amended | No |
| 2014-08-01 | This submission is the final filing | No |
| 2014-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-08-01 | Plan is a collectively bargained plan | No |
| 2014-08-01 | Plan funding arrangement – Insurance | Yes |
| 2014-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: VIGOR LLC HEALTH AND WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-08-01 | Type of plan entity | Single employer plan |
| 2013-08-01 | Submission has been amended | No |
| 2013-08-01 | This submission is the final filing | No |
| 2013-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-08-01 | Plan is a collectively bargained plan | No |
| 2013-08-01 | Plan funding arrangement – Insurance | Yes |
| 2013-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: VIGOR LLC HEALTH AND WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-08-01 | Type of plan entity | Single employer plan |
| 2012-08-01 | Submission has been amended | No |
| 2012-08-01 | This submission is the final filing | No |
| 2012-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-08-01 | Plan is a collectively bargained plan | No |
| 2012-08-01 | Plan funding arrangement – Insurance | Yes |
| 2012-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: VIGOR LLC HEALTH AND WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-08-01 | Type of plan entity | Single employer plan |
| 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) | No |
| 2011-08-01 | Plan is a collectively bargained plan | Yes |
| 2011-08-01 | Plan funding arrangement – Insurance | Yes |
| 2011-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: VIGOR LLC HEALTH AND WELFARE PLAN 2010 form 5500 responses |
|---|
| 2010-08-01 | Type of plan entity | Single employer plan |
| 2010-08-01 | Submission has been amended | No |
| 2010-08-01 | This submission is the final filing | No |
| 2010-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-08-01 | Plan is a collectively bargained plan | Yes |
| 2010-08-01 | Plan funding arrangement – Insurance | Yes |
| 2010-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: VIGOR LLC HEALTH AND WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-08-01 | Type of plan entity | Single employer plan |
| 2009-08-01 | Submission has been amended | No |
| 2009-08-01 | This submission is the final filing | No |
| 2009-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-08-01 | Plan is a collectively bargained plan | Yes |
| 2009-08-01 | Plan funding arrangement – Insurance | Yes |
| 2009-08-01 | Plan benefit arrangement – Insurance | Yes |
| RELIANT BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 15148965 |
| Policy instance | 3 |
| Insurance contract or identification number | 15148965 | | Number of Individuals Covered | 1500 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | 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 $39,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 101166 |
| Policy instance | 1 |
| Insurance contract or identification number | 101166 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,832 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 2 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $3,757 | | Total amount of fees paid to insurance company | USD $657 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $783,457 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,757 | | Amount paid for insurance broker fees | 657 | | Additional information about fees paid to insurance broker | RETENTION BONUS | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 16754 |
| Policy instance | 4 |
| Insurance contract or identification number | 16754 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $825 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,928 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $825 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 ) |
| Policy contract number | 107535 |
| Policy instance | 5 |
| Insurance contract or identification number | 107535 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $286,948 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 16754 |
| Policy instance | 6 |
| Insurance contract or identification number | 16754 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $3,555 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $95,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,555 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 ) |
| Policy contract number | 107535 |
| Policy instance | 7 |
| Insurance contract or identification number | 107535 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,114 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 754756 |
| Policy instance | 8 |
| Insurance contract or identification number | 754756 | | Number of Individuals Covered | 800 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $7,157 | | 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,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,439 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 2 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $4,364 | | Total amount of fees paid to insurance company | USD $846 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $730,877 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,364 | | Amount paid for insurance broker fees | 846 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 16754 |
| Policy instance | 4 |
| Insurance contract or identification number | 16754 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $3,557 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $118,007 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,557 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 754756 |
| Policy instance | 6 |
| Insurance contract or identification number | 754756 | | Number of Individuals Covered | 1030 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 107535 |
| Policy instance | 5 |
| Insurance contract or identification number | 107535 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $176,104 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANT BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 15148965 |
| Policy instance | 3 |
| Insurance contract or identification number | 15148965 | | Number of Individuals Covered | 1500 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | 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 $37,620 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 101166 |
| Policy instance | 1 |
| Insurance contract or identification number | 101166 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,823 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANT BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 15148965 |
| Policy instance | 3 |
| Insurance contract or identification number | 15148965 | | Number of Individuals Covered | 1500 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | 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 $18,810 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 2 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $3,510 | | Total amount of fees paid to insurance company | USD $561 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $703,135 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,510 | | Amount paid for insurance broker fees | 561 | | Additional information about fees paid to insurance broker | RETENTION BONUS NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 101166 |
| Policy instance | 1 |
| Insurance contract or identification number | 101166 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,933 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 754756 |
| Policy instance | 4 |
| Insurance contract or identification number | 754756 | | Number of Individuals Covered | 1148 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $5,704 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 5704 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 2 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $6,966 | | Total amount of fees paid to insurance company | USD $1,331 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,175,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,966 | | Amount paid for insurance broker fees | 1331 | | Additional information about fees paid to insurance broker | RETENTION BONUS NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 101166 |
| Policy instance | 1 |
| Insurance contract or identification number | 101166 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,383 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANT BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 15148965 |
| Policy instance | 3 |
| Insurance contract or identification number | 15148965 | | Number of Individuals Covered | 1500 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $1,881 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $47,027 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,881 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 754756 |
| Policy instance | 4 |
| Insurance contract or identification number | 754756 | | Number of Individuals Covered | 1291 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 754756 |
| Policy instance | 4 |
| Insurance contract or identification number | 754756 | | Number of Individuals Covered | 1649 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $8,270 | | Total amount of fees paid to insurance company | USD $10,000 | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 10000 | | Additional information about fees paid to insurance broker | ADMINISTRATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 3 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 604 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $15,884 | | Total amount of fees paid to insurance company | USD $4,170 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,298,693 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,884 | | Amount paid for insurance broker fees | 4170 | | Additional information about fees paid to insurance broker | FEES, RETENTION BONUS, NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 101166 |
| Policy instance | 2 |
| Insurance contract or identification number | 101166 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2016-09-01 | | Insurance policy end date | 2017-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,901 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR157 |
| Policy instance | 1 |
| Insurance contract or identification number | OR157 | | Number of Individuals Covered | 691 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $14,445 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,775 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR048086 |
| Policy instance | 5 |
| Insurance contract or identification number | OR048086 | | Number of Individuals Covered | 1943 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $9,650 | | Total amount of fees paid to insurance company | USD $7,230 | | 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 | EMPLOYEE ASSISTANCE PROGRAM | | 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 $977,711 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,650 | | Amount paid for insurance broker fees | 7230 | | Additional information about fees paid to insurance broker | INDIRECT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR157 |
| Policy instance | 4 |
| Insurance contract or identification number | OR157 | | Number of Individuals Covered | 580 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $13,644 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $13,644 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 3041 |
| Policy instance | 3 |
| Insurance contract or identification number | 3041 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $1,929 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 1 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 660 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $96,081 | | 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 | 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 $3,546,978 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $96,081 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 101166 |
| Policy instance | 2 |
| Insurance contract or identification number | 101166 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $27,464 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 1 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 688 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $984 | | 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 | 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 $2,880,951 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 984 | | Additional information about fees paid to insurance broker | RETENTION BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10003334 |
| Policy instance | 2 |
| Insurance contract or identification number | 10003334 | | Number of Individuals Covered | 2376 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $6,958 | | 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 | 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 $12,012,907 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 6958 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 3041 |
| Policy instance | 7 |
| Insurance contract or identification number | 3041 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $2,893 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 101166 |
| Policy instance | 6 |
| Insurance contract or identification number | 101166 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $36,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR048086 |
| Policy instance | 5 |
| Insurance contract or identification number | OR048086 | | Number of Individuals Covered | 1302 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $3,934 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | 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 $587,486 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,934 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10001778 |
| Policy instance | 4 |
| Insurance contract or identification number | 10001778 | | Number of Individuals Covered | 1837 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR157/Z1729 |
| Policy instance | 3 |
| Insurance contract or identification number | OR157/Z1729 | | Number of Individuals Covered | 779 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $20,604 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $20,604 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10001778 |
| Policy instance | 5 |
| Insurance contract or identification number | 10001778 | | Number of Individuals Covered | 657 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 1 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 487 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $45,437 | | 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 | 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 $2,686,679 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,437 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10003334 |
| Policy instance | 2 |
| Insurance contract or identification number | 10003334 | | Number of Individuals Covered | 1610 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $58,709 | | 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 | 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 $10,108,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,709 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 128700/168100 |
| Policy instance | 3 |
| Insurance contract or identification number | 128700/168100 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | 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 $328,539 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR157/Z1729 |
| Policy instance | 4 |
| Insurance contract or identification number | OR157/Z1729 | | Number of Individuals Covered | 809 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $21,741 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $10,905 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 107454 |
| Policy instance | 6 |
| Insurance contract or identification number | 107454 | | Number of Individuals Covered | 219 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $3,189 | | 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 | 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 $1,093,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,189 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR048086 |
| Policy instance | 7 |
| Insurance contract or identification number | OR048086 | | Number of Individuals Covered | 987 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $3,312 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $519,480 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,658 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 101166 |
| Policy instance | 8 |
| Insurance contract or identification number | 101166 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $70,906 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 3041 |
| Policy instance | 9 |
| Insurance contract or identification number | 3041 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $2,677 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018498 |
| Policy instance | 10 |
| Insurance contract or identification number | 50018498 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $1,730 | | 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 | Yes | | 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 $24,448 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,730 | | Insurance broker organization code? | 3 | | Insurance broker name | PREMERA BLUE CROSS |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10003334 |
| Policy instance | 2 |
| Insurance contract or identification number | 10003334 | | Number of Individuals Covered | 1835 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $451,277 | | Total amount of fees paid to insurance company | USD $11,732 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $10,282,084 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $451,277 | | Amount paid for insurance broker fees | 11732 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 101166 |
| Policy instance | 13 |
| Insurance contract or identification number | 101166 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $82,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | OR-101810 |
| Policy instance | 12 |
| Insurance contract or identification number | OR-101810 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $316 | | 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 | Yes | | 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 $7,321 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $316 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | OR-101810 |
| Policy instance | 11 |
| Insurance contract or identification number | OR-101810 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $1,185 | | 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 | Yes | | 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 $18,501 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,185 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 107454 |
| Policy instance | 9 |
| Insurance contract or identification number | 107454 | | Number of Individuals Covered | 219 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $10,179 | | 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 | 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 $285,963 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,179 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 107454 |
| Policy instance | 8 |
| Insurance contract or identification number | 107454 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $27,578 | | 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 | 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 $715,680 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,578 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10005097 |
| Policy instance | 7 |
| Insurance contract or identification number | 10005097 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $1,447 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,447 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10005097 |
| Policy instance | 6 |
| Insurance contract or identification number | 10005097 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $3,741 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,741 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10001778 |
| Policy instance | 5 |
| Insurance contract or identification number | 10001778 | | Number of Individuals Covered | 566 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $14,722 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,722 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR157/Z1729 |
| Policy instance | 4 |
| Insurance contract or identification number | OR157/Z1729 | | Number of Individuals Covered | 334 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $18,737 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $18,737 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 128700/168100 |
| Policy instance | 3 |
| Insurance contract or identification number | 128700/168100 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | 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 $301,478 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 3041 |
| Policy instance | 14 |
| Insurance contract or identification number | 3041 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $2,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 1 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 556 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $88,277 | | 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 | 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 $2,553,644 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $88,277 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
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| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR048086 |
| Policy instance | 10 |
| Insurance contract or identification number | OR048086 | | Number of Individuals Covered | 648 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $30,942 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $584,991 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,942 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 0168100 |
| Policy instance | 7 |
| Insurance contract or identification number | 0168100 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,897 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10001778 |
| Policy instance | 5 |
| Insurance contract or identification number | 10001778 | | Number of Individuals Covered | 597 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $13,018 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | Z1729 |
| Policy instance | 4 |
| Insurance contract or identification number | Z1729 | | Number of Individuals Covered | 339 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $13,165 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 3 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $56,709 | | Total amount of fees paid to insurance company | USD $1,911 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,544,304 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10003334 |
| Policy instance | 2 |
| Insurance contract or identification number | 10003334 | | Number of Individuals Covered | 868 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $195,623 | | Total amount of fees paid to insurance company | USD $62 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,920,574 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR048086 |
| Policy instance | 1 |
| Insurance contract or identification number | OR048086 | | Number of Individuals Covered | 450 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $25,209 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $407,832 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 0128700 |
| Policy instance | 6 |
| Insurance contract or identification number | 0128700 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $275,023 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 1530 |
| Policy instance | 5 |
| Insurance contract or identification number | 1530 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $44,246 | | Total amount of fees paid to insurance company | USD $1,250 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,429,390 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,246 | | Amount paid for insurance broker fees | 1250 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10001778 |
| Policy instance | 4 |
| Insurance contract or identification number | 10001778 | | Number of Individuals Covered | 319 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $8,710 | | Dental 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 $8,710 | | Insurance broker name | OAK TREE INSURANCE |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | Z1729 |
| Policy instance | 3 |
| Insurance contract or identification number | Z1729 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $9,063 | | Dental 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 $9,063 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10003334 |
| Policy instance | 2 |
| Insurance contract or identification number | 10003334 | | Number of Individuals Covered | 421 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $183,966 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,800,622 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $183,966 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSRUANCE, INC |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR048086 |
| Policy instance | 1 |
| Insurance contract or identification number | OR048086 | | Number of Individuals Covered | 453 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $16,531 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $213,862 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,531 | | Insurance broker organization code? | 3 | | Insurance broker name | OAK TREE INSURANCE, INC. |
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