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SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 401k Plan overview

Plan NameSCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN
Plan identification number 501

SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover

401k Sponsoring company profile

SCANDINAVIAN DESIGNS INC. has sponsored the creation of one or more 401k plans.

Company Name:SCANDINAVIAN DESIGNS INC.
Employer identification number (EIN):941721935
NAIC Classification:442110
NAIC Description:Furniture Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012018-01-01CONNIE HANSEN
5012017-01-01CONNIE HANSEN
5012016-01-01CONNIE HANSEN
5012015-01-01CONNIE HANSEN
5012014-01-01SHEILA CAULDWELL
5012013-01-01SHEILA CAULDWELL
5012012-01-01SHEILA CAULDWELL
5012011-01-01SHEILA CAULDWELL
5012010-01-01SHEILA CAULDWELL
5012009-01-01SHEILA CAULDWELL

Plan Statistics for SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN

401k plan membership statisitcs for SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN

Measure Date Value
2018: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01405
Total number of active participants reported on line 7a of the Form 55002018-01-01368
Number of retired or separated participants receiving benefits2018-01-013
Number of other retired or separated participants entitled to future benefits2018-01-0111
Total of all active and inactive participants2018-01-01382
2017: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01431
Total number of active participants reported on line 7a of the Form 55002017-01-01383
Number of retired or separated participants receiving benefits2017-01-014
Number of other retired or separated participants entitled to future benefits2017-01-0118
Total of all active and inactive participants2017-01-01405
2016: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01406
Total number of active participants reported on line 7a of the Form 55002016-01-01416
Number of retired or separated participants receiving benefits2016-01-016
Number of other retired or separated participants entitled to future benefits2016-01-019
Total of all active and inactive participants2016-01-01431
2015: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01429
Total number of active participants reported on line 7a of the Form 55002015-01-01406
Number of retired or separated participants receiving benefits2015-01-012
Number of other retired or separated participants entitled to future benefits2015-01-0120
Total of all active and inactive participants2015-01-01428
2014: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01442
Total number of active participants reported on line 7a of the Form 55002014-01-01412
Number of retired or separated participants receiving benefits2014-01-013
Number of other retired or separated participants entitled to future benefits2014-01-0114
Total of all active and inactive participants2014-01-01429
2013: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01480
Total number of active participants reported on line 7a of the Form 55002013-01-01416
Number of retired or separated participants receiving benefits2013-01-0111
Number of other retired or separated participants entitled to future benefits2013-01-0115
Total of all active and inactive participants2013-01-01442
2012: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01473
Total number of active participants reported on line 7a of the Form 55002012-01-01459
Number of retired or separated participants receiving benefits2012-01-014
Number of other retired or separated participants entitled to future benefits2012-01-0117
Total of all active and inactive participants2012-01-01480
2011: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01407
Total number of active participants reported on line 7a of the Form 55002011-01-01454
Number of retired or separated participants receiving benefits2011-01-014
Number of other retired or separated participants entitled to future benefits2011-01-0115
Total of all active and inactive participants2011-01-01473
2010: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01421
Total number of active participants reported on line 7a of the Form 55002010-01-01396
Number of retired or separated participants receiving benefits2010-01-016
Number of other retired or separated participants entitled to future benefits2010-01-015
Total of all active and inactive participants2010-01-01407
2009: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01450
Total number of active participants reported on line 7a of the Form 55002009-01-01403
Number of retired or separated participants receiving benefits2009-01-016
Number of other retired or separated participants entitled to future benefits2009-01-0112
Total of all active and inactive participants2009-01-01421

Form 5500 Responses for SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN

2018: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01Type of plan entityMulitple employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01Type of plan entityMulitple employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01Type of plan entityMulitple employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-01-01Type of plan entityMulitple employer plan
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: SCANDINAVIAN DESIGNS INC. - WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01Type of plan entityMulitple employer plan
2009-01-01This submission is the final filingNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number3180
Policy instance 2
Insurance contract or identification number3180
Number of Individuals Covered32
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $3,233
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $102,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,233
Insurance broker organization code?3
WESTERN HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number950120
Policy instance 16
Insurance contract or identification number950120
Number of Individuals Covered27
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $8,917
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $178,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,917
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberB14114
Policy instance 1
Insurance contract or identification numberB14114
Number of Individuals Covered40
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $12,687
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $254,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,687
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )
Policy contract number26946
Policy instance 3
Insurance contract or identification number26946
Number of Individuals Covered20
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $6,650
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $130,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,650
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number38214
Policy instance 4
Insurance contract or identification number38214
Number of Individuals Covered125
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $31,954
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $695,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,954
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225392
Policy instance 5
Insurance contract or identification number225392
Number of Individuals Covered107
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $23,495
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $510,643
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,495
Insurance broker organization code?3
SAINT MARYS HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 11079 )
Policy contract numberGRP0003874
Policy instance 6
Insurance contract or identification numberGRP0003874
Number of Individuals Covered3
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $910
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $51,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $910
Insurance broker organization code?3
GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )
Policy contract number1502500
Policy instance 7
Insurance contract or identification number1502500
Number of Individuals Covered71
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $12,642
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $309,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,642
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract numberMG-115OP122107
Policy instance 8
Insurance contract or identification numberMG-115OP122107
Number of Individuals Covered4
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $1,421
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedGAP DEDUCTIBLE INSURANCE
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 CarrierUSD $9,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,421
Insurance broker organization code?3
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number142632
Policy instance 9
Insurance contract or identification number142632
Number of Individuals Covered3
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $925
Total amount of fees paid to insurance companyUSD $72
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $14,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $925
Amount paid for insurance broker fees72
Additional information about fees paid to insurance brokerBROKER INCENTIVE PROGRAM
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3337843
Policy instance 15
Insurance contract or identification number3337843
Number of Individuals Covered328
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $12,422
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $251,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,422
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30032239
Policy instance 14
Insurance contract or identification number30032239
Number of Individuals Covered200
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $1,271
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $25,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,271
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX965982
Policy instance 13
Insurance contract or identification numberFLX965982
Number of Individuals Covered402
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $8,391
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedBASIC LIFE, SUPP. LIFE, DEPENDENT LIFE
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 CarrierUSD $56,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,391
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961606
Policy instance 12
Insurance contract or identification numberVDT961606
Number of Individuals Covered135
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $4,624
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedWEEKLY INCOME
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 CarrierUSD $30,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,624
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961607
Policy instance 11
Insurance contract or identification numberVDT961607
Number of Individuals Covered83
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $4,666
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $31,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,666
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 967537
Policy instance 10
Insurance contract or identification numberOK 967537
Number of Individuals Covered402
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $493
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $493
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract numberMG-115OP122107
Policy instance 8
Insurance contract or identification numberMG-115OP122107
Number of Individuals Covered4
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $7,489
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedGAP DEDUCTIBLE INSURANCE
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 CarrierUSD $49,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,489
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE
GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )
Policy contract number1502500
Policy instance 7
Insurance contract or identification number1502500
Number of Individuals Covered46
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $7,679
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $278,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,679
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SVCS
SAINT MARYS HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 11079 )
Policy contract numberGRP0003874
Policy instance 6
Insurance contract or identification numberGRP0003874
Number of Individuals Covered7
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $2,700
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $17,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,700
Insurance broker organization code?3
Insurance broker nameJOHN JAKIEMIEC
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number3180
Policy instance 2
Insurance contract or identification number3180
Number of Individuals Covered46
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $5,148
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $174,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,148
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225392
Policy instance 5
Insurance contract or identification number225392
Number of Individuals Covered129
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $28,979
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $579,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,979
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberB14114
Policy instance 1
Insurance contract or identification numberB14114
Number of Individuals Covered42
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $12,655
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $284,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,655
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number38214
Policy instance 4
Insurance contract or identification number38214
Number of Individuals Covered132
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $42,719
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $856,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,719
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number142632
Policy instance 9
Insurance contract or identification number142632
Number of Individuals Covered6
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $1,545
Total amount of fees paid to insurance companyUSD $88
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $29,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,545
Amount paid for insurance broker fees88
Additional information about fees paid to insurance brokerBROKER INCENTIVE PROGRAM
Insurance broker organization code?3
Insurance broker nameHORIZON AGENCY INC, SCOTT S HASKINS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 967537
Policy instance 10
Insurance contract or identification numberOK 967537
Number of Individuals Covered383
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $638
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $638
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961607
Policy instance 11
Insurance contract or identification numberVDT961607
Number of Individuals Covered89
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $5,965
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $39,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,965
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )
Policy contract number26946
Policy instance 3
Insurance contract or identification number26946
Number of Individuals Covered21
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $10,154
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $198,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,154
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
WESTERN HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number950120
Policy instance 17
Insurance contract or identification number950120
Number of Individuals Covered26
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $11,076
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $221,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,076
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number6492600
Policy instance 16
Insurance contract or identification number6492600
Number of Individuals Covered40
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $6,594
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $219,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,594
Insurance broker organization code?3
Insurance broker nameJOHN JAKIEMIEC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3337843
Policy instance 15
Insurance contract or identification number3337843
Number of Individuals Covered338
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $13,371
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $270,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,371
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30032239
Policy instance 14
Insurance contract or identification number30032239
Number of Individuals Covered183
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $1,249
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $24,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,249
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX965982
Policy instance 13
Insurance contract or identification numberFLX965982
Number of Individuals Covered412
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $10,585
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedBASIC LIFE, SUPP. LIFE, DEPENDENT LIFE
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 CarrierUSD $70,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,585
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961606
Policy instance 12
Insurance contract or identification numberVDT961606
Number of Individuals Covered153
Insurance policy start date2016-04-01
Insurance policy end date2017-03-31
Total amount of commissions paid to insurance brokerUSD $6,725
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedWEEKLY INCOME
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 CarrierUSD $44,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,725
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
SAINT MARYS HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 11079 )
Policy contract numberARID0003819
Policy instance 6
Insurance contract or identification numberARID0003819
Number of Individuals Covered7
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $2,954
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $59,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,954
Insurance broker organization code?3
Insurance broker nameJOHN JAKIEMIEC
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number5292200
Policy instance 7
Insurance contract or identification number5292200
Number of Individuals Covered43
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $6,648
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $195,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,648
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract numberMG-115OP122107
Policy instance 8
Insurance contract or identification numberMG-115OP122107
Number of Individuals Covered93
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $10,540
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedGAP DEDUCTIBLE INSURANCE
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 CarrierUSD $70,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,540
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number142632
Policy instance 9
Insurance contract or identification number142632
Number of Individuals Covered8
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $1,051
Total amount of fees paid to insurance companyUSD $18
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $24,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,051
Amount paid for insurance broker fees18
Additional information about fees paid to insurance brokerBROKER INCENTIVE PROGRAM
Insurance broker organization code?3
Insurance broker nameHORIZON AGENCY INC, SCOTT S HASKINS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 967537
Policy instance 10
Insurance contract or identification numberOK 967537
Number of Individuals Covered406
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $503
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $503
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961607
Policy instance 11
Insurance contract or identification numberVDT961607
Number of Individuals Covered71
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $3,549
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $23,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,549
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961606
Policy instance 12
Insurance contract or identification numberVDT961606
Number of Individuals Covered168
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $5,420
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedWEEKLY INCOME
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 CarrierUSD $36,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,420
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0141051
Policy instance 14
Insurance contract or identification number0141051
Number of Individuals Covered0
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $246
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $246
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30032239
Policy instance 15
Insurance contract or identification number30032239
Number of Individuals Covered182
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $1,222
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $23,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,222
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3337843
Policy instance 16
Insurance contract or identification number3337843
Number of Individuals Covered359
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $13,066
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $264,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,066
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )
Policy contract number1502500
Policy instance 17
Insurance contract or identification number1502500
Number of Individuals Covered48
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $7,285
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $265,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,285
Insurance broker organization code?3
Insurance broker nameJOHN JAKIEMIEC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225392
Policy instance 5
Insurance contract or identification number225392
Number of Individuals Covered142
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $28,040
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $610,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,040
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number38214
Policy instance 4
Insurance contract or identification number38214
Number of Individuals Covered150
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $45,618
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $992,360
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $45,618
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )
Policy contract number26946
Policy instance 3
Insurance contract or identification number26946
Number of Individuals Covered33
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $7,649
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $155,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,649
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number3180
Policy instance 2
Insurance contract or identification number3180
Number of Individuals Covered41
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $4,310
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $156,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,310
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberB14114
Policy instance 1
Insurance contract or identification numberB14114
Number of Individuals Covered57
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $15,290
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $316,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,290
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX965982
Policy instance 13
Insurance contract or identification numberFLX965982
Number of Individuals Covered406
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $7,974
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE & AD&D
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 CarrierUSD $53,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,974
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberB14114
Policy instance 1
Insurance contract or identification numberB14114
Number of Individuals Covered64
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $16,774
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $333,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,774
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )
Policy contract number26946
Policy instance 3
Insurance contract or identification number26946
Number of Individuals Covered30
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $6,182
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $134,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,182
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225392
Policy instance 5
Insurance contract or identification number225392
Number of Individuals Covered142
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $28,766
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $574,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,766
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number5292100
Policy instance 7
Insurance contract or identification number5292100
Number of Individuals Covered86
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $14,718
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $409,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,718
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
SAINT MARYS HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 11079 )
Policy contract numberARID0003819
Policy instance 6
Insurance contract or identification numberARID0003819
Number of Individuals Covered8
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $2,562
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $51,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,562
Insurance broker organization code?3
Insurance broker nameJOHN JAKIEMIEC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract numberMG-115OP122107
Policy instance 8
Insurance contract or identification numberMG-115OP122107
Number of Individuals Covered103
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $9,328
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedGAP DEDUCTIBLE INSURANCE
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 CarrierUSD $62,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,328
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number38214
Policy instance 4
Insurance contract or identification number38214
Number of Individuals Covered175
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $51,096
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,020,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,096
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number142632
Policy instance 9
Insurance contract or identification number142632
Number of Individuals Covered32
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $1,350
Total amount of fees paid to insurance companyUSD $23
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $21,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $810
Insurance broker organization code?3
Amount paid for insurance broker fees23
Additional information about fees paid to insurance brokerBROKER INCENTIVE PROGRAM
Insurance broker nameHORIZON AGENCY INC, STEVEN W HASKIN
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113992
Policy instance 10
Insurance contract or identification number000010113992
Number of Individuals Covered412
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $1,583
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,583
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113993
Policy instance 11
Insurance contract or identification number000010113993
Number of Individuals Covered412
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $4,390
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $47,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,390
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113994
Policy instance 12
Insurance contract or identification number000010113994
Number of Individuals Covered165
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $2,681
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedWEEKLY INCOME
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 CarrierUSD $38,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,681
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number400001000-09785
Policy instance 13
Insurance contract or identification number400001000-09785
Number of Individuals Covered99
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $7,865
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE & AD&D
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 CarrierUSD $52,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,865
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0141051
Policy instance 14
Insurance contract or identification number0141051
Number of Individuals Covered611
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $6,425
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $288,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,425
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30032239
Policy instance 15
Insurance contract or identification number30032239
Number of Individuals Covered193
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $1,215
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $23,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,215
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number3180
Policy instance 2
Insurance contract or identification number3180
Number of Individuals Covered39
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $6,432
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $141,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,432
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number3180
Policy instance 2
Insurance contract or identification number3180
Number of Individuals Covered41
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $7,520
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $138,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,520
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225392
Policy instance 5
Insurance contract or identification number225392
Number of Individuals Covered161
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $32,374
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $647,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,374
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
SAINT MARYS HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 11079 )
Policy contract numberARID0003819
Policy instance 6
Insurance contract or identification numberARID0003819
Number of Individuals Covered9
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $2,655
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $53,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,655
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number5292100
Policy instance 7
Insurance contract or identification number5292100
Number of Individuals Covered57
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $9,325
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $311,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,325
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number5292200
Policy instance 8
Insurance contract or identification number5292200
Number of Individuals Covered32
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $3,834
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $127,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,834
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113992
Policy instance 10
Insurance contract or identification number000010113992
Number of Individuals Covered417
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $1,438
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $12,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,438
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113993
Policy instance 11
Insurance contract or identification number000010113993
Number of Individuals Covered416
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $4,458
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $49,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,458
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number142632
Policy instance 9
Insurance contract or identification number142632
Number of Individuals Covered4
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $1,560
Total amount of fees paid to insurance companyUSD $23
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,560
Insurance broker organization code?3
Amount paid for insurance broker fees23
Additional information about fees paid to insurance brokerBROKER INCENTIVE PROGRAM
Insurance broker nameHORIZON AGENCY INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113994
Policy instance 12
Insurance contract or identification number000010113994
Number of Individuals Covered176
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $2,768
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedWEEKLY INCOME
Welfare Benefit Premiums Paid to CarrierUSD $42,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,768
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number400001000-09785
Policy instance 13
Insurance contract or identification number400001000-09785
Number of Individuals Covered108
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $8,522
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedVOLUNTARY LIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $56,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,522
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0141051
Policy instance 14
Insurance contract or identification number0141051
Number of Individuals Covered652
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $6,438
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $287,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,438
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30032239
Policy instance 15
Insurance contract or identification number30032239
Number of Individuals Covered164
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $1,141
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,141
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number38214
Policy instance 4
Insurance contract or identification number38214
Number of Individuals Covered183
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $53,361
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $1,067,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,361
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )
Policy contract number26946
Policy instance 3
Insurance contract or identification number26946
Number of Individuals Covered22
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $7,418
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $157,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,418
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberB14114
Policy instance 1
Insurance contract or identification numberB14114
Number of Individuals Covered73
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $18,756
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $377,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,756
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberB14114
Policy instance 1
Insurance contract or identification numberB14114
Number of Individuals Covered75
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $18,552
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $372,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,552
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )
Policy contract number26946
Policy instance 3
Insurance contract or identification number26946
Number of Individuals Covered28
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $6,559
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $158,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,559
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number38214
Policy instance 4
Insurance contract or identification number38214
Number of Individuals Covered194
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $51,481
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $939,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,481
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225392
Policy instance 5
Insurance contract or identification number225392
Number of Individuals Covered163
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $32,139
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $585,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,139
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
SAINT MARYS HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 11079 )
Policy contract numberARID0003819
Policy instance 6
Insurance contract or identification numberARID0003819
Number of Individuals Covered9
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $2,349
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $45,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,349
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number5292100
Policy instance 7
Insurance contract or identification number5292100
Number of Individuals Covered61
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $9,441
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $316,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,441
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number5292200
Policy instance 8
Insurance contract or identification number5292200
Number of Individuals Covered36
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $3,840
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $127,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,840
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113992
Policy instance 10
Insurance contract or identification number000010113992
Number of Individuals Covered454
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $1,388
Total amount of fees paid to insurance companyUSD $555
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $12,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,388
Amount paid for insurance broker fees555
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113993
Policy instance 11
Insurance contract or identification number000010113993
Number of Individuals Covered455
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $4,359
Total amount of fees paid to insurance companyUSD $2,157
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $47,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,359
Amount paid for insurance broker fees2157
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113994
Policy instance 12
Insurance contract or identification number000010113994
Number of Individuals Covered199
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $2,805
Total amount of fees paid to insurance companyUSD $2,002
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedWEEKLY INCOME
Welfare Benefit Premiums Paid to CarrierUSD $44,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,805
Amount paid for insurance broker fees2002
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number400001000-09785
Policy instance 13
Insurance contract or identification number400001000-09785
Number of Individuals Covered120
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $8,246
Total amount of fees paid to insurance companyUSD $2,370
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedVOLUNTARY LIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $54,976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,246
Amount paid for insurance broker fees2370
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0141051
Policy instance 14
Insurance contract or identification number0141051
Number of Individuals Covered705
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $6,529
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $300,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,529
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number3180
Policy instance 2
Insurance contract or identification number3180
Number of Individuals Covered40
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $6,202
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $142,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,202
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number142632
Policy instance 9
Insurance contract or identification number142632
Number of Individuals Covered4
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $1,350
Total amount of fees paid to insurance companyUSD $56
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,350
Insurance broker organization code?3
Amount paid for insurance broker fees56
Additional information about fees paid to insurance brokerBROKER INCENTIVE PROGRAM
Insurance broker nameHORIZON AGENCY INC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225392
Policy instance 5
Insurance contract or identification number225392
Number of Individuals Covered163
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $27,182
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $531,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberB14114
Policy instance 1
Insurance contract or identification numberB14114
Number of Individuals Covered81
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $18,032
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $359,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )
Policy contract number26946
Policy instance 3
Insurance contract or identification number26946
Number of Individuals Covered31
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $7,095
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $143,173
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 number38214
Policy instance 4
Insurance contract or identification number38214
Number of Individuals Covered192
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $44,218
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $862,163
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 number3180
Policy instance 2
Insurance contract or identification number3180
Number of Individuals Covered47
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $6,298
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $146,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAINT MARYS HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 11079 )
Policy contract numberH01170
Policy instance 6
Insurance contract or identification numberH01170
Number of Individuals Covered8
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $4,327
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $50,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number5292100
Policy instance 7
Insurance contract or identification number5292100
Number of Individuals Covered58
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $7,771
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $259,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number5292200
Policy instance 8
Insurance contract or identification number5292200
Number of Individuals Covered34
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $3,792
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $126,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number142632
Policy instance 9
Insurance contract or identification number142632
Number of Individuals Covered6
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $1,714
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $33,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0141051
Policy instance 14
Insurance contract or identification number0141051
Number of Individuals Covered707
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $6,317
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $273,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number400001000-09785
Policy instance 13
Insurance contract or identification number400001000-09785
Number of Individuals Covered131
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $8,064
Total amount of fees paid to insurance companyUSD $768
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedVOLUNTARY LIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $53,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113993
Policy instance 11
Insurance contract or identification number000010113993
Number of Individuals Covered462
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $4,390
Total amount of fees paid to insurance companyUSD $758
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $47,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113992
Policy instance 10
Insurance contract or identification number000010113992
Number of Individuals Covered461
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $1,396
Total amount of fees paid to insurance companyUSD $196
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $12,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113994
Policy instance 12
Insurance contract or identification number000010113994
Number of Individuals Covered208
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $2,802
Total amount of fees paid to insurance companyUSD $668
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedWEEKLY INCOME
Welfare Benefit Premiums Paid to CarrierUSD $44,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAINT MARY'S HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 95793 )
Policy contract numberH01170
Policy instance 6
Insurance contract or identification numberH01170
Number of Individuals Covered10
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $2,944
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $33,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees2944
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number5292100
Policy instance 7
Insurance contract or identification number5292100
Number of Individuals Covered56
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $6,807
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $226,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,807
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number5292200
Policy instance 8
Insurance contract or identification number5292200
Number of Individuals Covered41
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $4,805
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $160,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,805
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number142632
Policy instance 9
Insurance contract or identification number142632
Number of Individuals Covered6
Insurance policy start date2009-05-01
Insurance policy end date2010-04-30
Total amount of commissions paid to insurance brokerUSD $1,335
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,320
Insurance broker organization code?3
Insurance broker nameHORIZON AGENCY INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113992
Policy instance 10
Insurance contract or identification number000010113992
Number of Individuals Covered459
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $1,441
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $12,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,441
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113993
Policy instance 11
Insurance contract or identification number000010113993
Number of Individuals Covered459
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $4,499
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $49,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,499
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010113994
Policy instance 12
Insurance contract or identification number000010113994
Number of Individuals Covered208
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $2,797
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedWEEKLY INCOME
Welfare Benefit Premiums Paid to CarrierUSD $44,360
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,797
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )
Policy contract number26946
Policy instance 3
Insurance contract or identification number26946
Number of Individuals Covered29
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $5,569
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $121,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,569
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number400001000-09785
Policy instance 13
Insurance contract or identification number400001000-09785
Number of Individuals Covered130
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $7,619
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedVOLUNTARY LIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $50,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,619
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0141051
Policy instance 14
Insurance contract or identification number0141051
Number of Individuals Covered702
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $5,953
Total amount of fees paid to insurance companyUSD $4,060
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $265,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,953
Amount paid for insurance broker fees4060
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number38214
Policy instance 4
Insurance contract or identification number38214
Number of Individuals Covered196
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $34,900
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $797,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,900
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberB14114
Policy instance 1
Insurance contract or identification numberB14114
Number of Individuals Covered72
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $19,182
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $384,422
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,182
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225392
Policy instance 5
Insurance contract or identification number225392
Number of Individuals Covered166
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $22,063
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $506,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,063
Insurance broker organization code?3
Insurance broker nameNORTHGATE BENEFITS & INSURANCE SERV
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number3180
Policy instance 2
Insurance contract or identification number3180
Number of Individuals Covered45
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $5,769
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedHEALTH CARE SERVICE PLAN
Welfare Benefit Premiums Paid to CarrierUSD $135,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,769
Insurance broker organization code?3
Insurance broker nameJOHN G JAKIEMIEC

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