GROSVENOR PROPERTIES LTD. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan GROSVENOR PROPERTIES LTD.
401k plan membership statisitcs for GROSVENOR PROPERTIES LTD.
| Measure | Date | Value |
|---|
| 2018: GROSVENOR PROPERTIES LTD. 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 17 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 16 |
| Total of all active and inactive participants | 2018-01-01 | 16 |
| Total participants | 2018-01-01 | 16 |
| 2017: GROSVENOR PROPERTIES LTD. 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 17 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 17 |
| Total of all active and inactive participants | 2017-12-01 | 17 |
| Total participants | 2017-12-01 | 17 |
| 2016: GROSVENOR PROPERTIES LTD. 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 16 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 17 |
| Total of all active and inactive participants | 2016-12-01 | 17 |
| Total participants | 2016-12-01 | 17 |
| 2015: GROSVENOR PROPERTIES LTD. 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 17 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 14 |
| Number of retired or separated participants receiving benefits | 2015-12-01 | 0 |
| Total of all active and inactive participants | 2015-12-01 | 14 |
| Total participants | 2015-12-01 | 14 |
| Total participants, beginning-of-year | 2015-08-01 | 15 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-08-01 | 16 |
| Number of retired or separated participants receiving benefits | 2015-08-01 | 0 |
| Total of all active and inactive participants | 2015-08-01 | 16 |
| Total participants | 2015-08-01 | 16 |
| 2014: GROSVENOR PROPERTIES LTD. 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-08-01 | 15 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-08-01 | 15 |
| Number of retired or separated participants receiving benefits | 2014-08-01 | 0 |
| Total of all active and inactive participants | 2014-08-01 | 15 |
| Total participants | 2014-08-01 | 15 |
| 2013: GROSVENOR PROPERTIES LTD. 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-08-01 | 18 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-08-01 | 15 |
| Number of retired or separated participants receiving benefits | 2013-08-01 | 0 |
| Total of all active and inactive participants | 2013-08-01 | 15 |
| Total participants | 2013-08-01 | 15 |
| 2012: GROSVENOR PROPERTIES LTD. 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-08-01 | 21 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-08-01 | 18 |
| Number of retired or separated participants receiving benefits | 2012-08-01 | 3 |
| Total of all active and inactive participants | 2012-08-01 | 21 |
| Total participants | 2012-08-01 | 21 |
| 2011: GROSVENOR PROPERTIES LTD. 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-08-01 | 37 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-08-01 | 20 |
| Number of retired or separated participants receiving benefits | 2011-08-01 | 3 |
| Total of all active and inactive participants | 2011-08-01 | 23 |
| Total participants | 2011-08-01 | 23 |
| Total participants, beginning-of-year | 2011-07-01 | 37 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 36 |
| Number of retired or separated participants receiving benefits | 2011-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-07-01 | 0 |
| Total of all active and inactive participants | 2011-07-01 | 36 |
| Total participants | 2011-07-01 | 36 |
| 2009: GROSVENOR PROPERTIES LTD. 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-07-01 | 45 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 41 |
| Number of retired or separated participants receiving benefits | 2009-07-01 | 2 |
| Total of all active and inactive participants | 2009-07-01 | 43 |
| Total participants | 2009-07-01 | 43 |
| Measure | Date | Value |
|---|
| 2018 : GROSVENOR PROPERTIES LTD. 2018 401k financial data |
|---|
| Total income from all sources | 2018-12-31 | $288,318 |
| Expenses. Total of all expenses incurred | 2018-12-31 | $288,318 |
| Benefits paid (including direct rollovers) | 2018-12-31 | $288,318 |
| Total plan assets at end of year | 2018-12-31 | $0 |
| Total plan assets at beginning of year | 2018-12-31 | $0 |
| Value of fidelity bond covering the plan | 2018-12-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2018-12-31 | $73,335 |
| Net income (gross income less expenses) | 2018-12-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2018-12-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2018-12-31 | $0 |
| Total contributions received or receivable from employer(s) | 2018-12-31 | $214,983 |
| 2017 : GROSVENOR PROPERTIES LTD. 2017 401k financial data |
|---|
| Total income from all sources | 2017-12-31 | $25,276 |
| Expenses. Total of all expenses incurred | 2017-12-31 | $25,276 |
| Benefits paid (including direct rollovers) | 2017-12-31 | $25,276 |
| Total plan assets at end of year | 2017-12-31 | $0 |
| Total plan assets at beginning of year | 2017-12-31 | $0 |
| Value of fidelity bond covering the plan | 2017-12-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2017-12-31 | $5,721 |
| Net income (gross income less expenses) | 2017-12-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2017-12-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2017-12-31 | $0 |
| Total contributions received or receivable from employer(s) | 2017-12-31 | $19,555 |
| Total income from all sources | 2017-11-30 | $261,533 |
| Expenses. Total of all expenses incurred | 2017-11-30 | $261,533 |
| Benefits paid (including direct rollovers) | 2017-11-30 | $261,533 |
| Total plan assets at end of year | 2017-11-30 | $0 |
| Total plan assets at beginning of year | 2017-11-30 | $0 |
| Value of fidelity bond covering the plan | 2017-11-30 | $1,000,000 |
| Total contributions received or receivable from participants | 2017-11-30 | $66,941 |
| Net income (gross income less expenses) | 2017-11-30 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2017-11-30 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2017-11-30 | $0 |
| Total contributions received or receivable from employer(s) | 2017-11-30 | $194,592 |
| 2016 : GROSVENOR PROPERTIES LTD. 2016 401k financial data |
|---|
| Total income from all sources | 2016-11-30 | $271,221 |
| Expenses. Total of all expenses incurred | 2016-11-30 | $271,221 |
| Benefits paid (including direct rollovers) | 2016-11-30 | $271,150 |
| Total plan assets at end of year | 2016-11-30 | $0 |
| Total plan assets at beginning of year | 2016-11-30 | $0 |
| Value of fidelity bond covering the plan | 2016-11-30 | $1,000,000 |
| Total contributions received or receivable from participants | 2016-11-30 | $91,624 |
| Net income (gross income less expenses) | 2016-11-30 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2016-11-30 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2016-11-30 | $0 |
| Total contributions received or receivable from employer(s) | 2016-11-30 | $179,597 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2016-11-30 | $71 |
| 2015 : GROSVENOR PROPERTIES LTD. 2015 401k financial data |
|---|
| Total income from all sources | 2015-11-30 | $90,778 |
| Expenses. Total of all expenses incurred | 2015-11-30 | $90,778 |
| Benefits paid (including direct rollovers) | 2015-11-30 | $90,754 |
| Total plan assets at end of year | 2015-11-30 | $0 |
| Total plan assets at beginning of year | 2015-11-30 | $0 |
| Value of fidelity bond covering the plan | 2015-11-30 | $1,000,000 |
| Total contributions received or receivable from participants | 2015-11-30 | $31,181 |
| Net income (gross income less expenses) | 2015-11-30 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2015-11-30 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2015-11-30 | $0 |
| Total contributions received or receivable from employer(s) | 2015-11-30 | $59,597 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2015-11-30 | $24 |
| Total plan liabilities at end of year | 2015-07-31 | $0 |
| Total plan liabilities at beginning of year | 2015-07-31 | $0 |
| Total income from all sources | 2015-07-31 | $259,285 |
| Expenses. Total of all expenses incurred | 2015-07-31 | $259,285 |
| Benefits paid (including direct rollovers) | 2015-07-31 | $259,214 |
| Total plan assets at end of year | 2015-07-31 | $0 |
| Total plan assets at beginning of year | 2015-07-31 | $0 |
| Value of fidelity bond covering the plan | 2015-07-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2015-07-31 | $87,836 |
| Net income (gross income less expenses) | 2015-07-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2015-07-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2015-07-31 | $0 |
| Total contributions received or receivable from employer(s) | 2015-07-31 | $171,449 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2015-07-31 | $71 |
| 2014 : GROSVENOR PROPERTIES LTD. 2014 401k financial data |
|---|
| Total income from all sources | 2014-07-31 | $239,067 |
| Expenses. Total of all expenses incurred | 2014-07-31 | $239,067 |
| Benefits paid (including direct rollovers) | 2014-07-31 | $238,996 |
| Total plan assets at end of year | 2014-07-31 | $0 |
| Total plan assets at beginning of year | 2014-07-31 | $0 |
| Value of fidelity bond covering the plan | 2014-07-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2014-07-31 | $85,313 |
| Net income (gross income less expenses) | 2014-07-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2014-07-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2014-07-31 | $0 |
| Total contributions received or receivable from employer(s) | 2014-07-31 | $153,754 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2014-07-31 | $71 |
| 2013 : GROSVENOR PROPERTIES LTD. 2013 401k financial data |
|---|
| Total income from all sources | 2013-07-31 | $258,877 |
| Expenses. Total of all expenses incurred | 2013-07-31 | $258,877 |
| Benefits paid (including direct rollovers) | 2013-07-31 | $258,806 |
| Total plan assets at end of year | 2013-07-31 | $0 |
| Total plan assets at beginning of year | 2013-07-31 | $0 |
| Value of fidelity bond covering the plan | 2013-07-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2013-07-31 | $100,861 |
| Net income (gross income less expenses) | 2013-07-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2013-07-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2013-07-31 | $0 |
| Total contributions received or receivable from employer(s) | 2013-07-31 | $158,016 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2013-07-31 | $71 |
| 2012 : GROSVENOR PROPERTIES LTD. 2012 401k financial data |
|---|
| Total income from all sources | 2012-07-31 | $443,222 |
| Expenses. Total of all expenses incurred | 2012-07-31 | $443,222 |
| Benefits paid (including direct rollovers) | 2012-07-31 | $443,026 |
| Total plan assets at end of year | 2012-07-31 | $0 |
| Total plan assets at beginning of year | 2012-07-31 | $0 |
| Value of fidelity bond covering the plan | 2012-07-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2012-07-31 | $156,841 |
| Net income (gross income less expenses) | 2012-07-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2012-07-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2012-07-31 | $0 |
| Total contributions received or receivable from employer(s) | 2012-07-31 | $286,381 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2012-07-31 | $196 |
| 2011 : GROSVENOR PROPERTIES LTD. 2011 401k financial data |
|---|
| Total income from all sources | 2011-07-31 | $48,990 |
| Expenses. Total of all expenses incurred | 2011-07-31 | $48,990 |
| Benefits paid (including direct rollovers) | 2011-07-31 | $48,990 |
| Total plan assets at end of year | 2011-07-31 | $0 |
| Total plan assets at beginning of year | 2011-07-31 | $0 |
| Value of fidelity bond covering the plan | 2011-07-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2011-07-31 | $12,691 |
| Net income (gross income less expenses) | 2011-07-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2011-07-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2011-07-31 | $0 |
| Total contributions received or receivable from employer(s) | 2011-07-31 | $36,299 |
| Total plan liabilities at end of year | 2011-06-30 | $0 |
| Total plan liabilities at beginning of year | 2011-06-30 | $0 |
| Total income from all sources | 2011-06-30 | $563,036 |
| Expenses. Total of all expenses incurred | 2011-06-30 | $563,036 |
| Benefits paid (including direct rollovers) | 2011-06-30 | $563,036 |
| Total plan assets at end of year | 2011-06-30 | $0 |
| Total plan assets at beginning of year | 2011-06-30 | $0 |
| Value of fidelity bond covering the plan | 2011-06-30 | $1,000,000 |
| Total contributions received or receivable from participants | 2011-06-30 | $191,043 |
| Net income (gross income less expenses) | 2011-06-30 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2011-06-30 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2011-06-30 | $0 |
| Total contributions received or receivable from employer(s) | 2011-06-30 | $371,993 |
| 2018: GROSVENOR PROPERTIES LTD. 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: GROSVENOR PROPERTIES LTD. 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Submission has been amended | No |
| 2017-12-01 | This submission is the final filing | No |
| 2017-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-12-01 | Plan is a collectively bargained plan | No |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: GROSVENOR PROPERTIES LTD. 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Submission has been amended | No |
| 2016-12-01 | This submission is the final filing | No |
| 2016-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-12-01 | Plan is a collectively bargained plan | No |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: GROSVENOR PROPERTIES LTD. 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-08-01 | Type of plan entity | Single employer plan |
| 2015-08-01 | Submission has been amended | No |
| 2015-08-01 | This submission is the final filing | No |
| 2015-08-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2015-08-01 | Plan is a collectively bargained plan | No |
| 2015-08-01 | Plan funding arrangement – Insurance | Yes |
| 2015-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: GROSVENOR PROPERTIES LTD. 2014 form 5500 responses |
|---|
| 2014-08-01 | Type of plan entity | Single employer plan |
| 2014-08-01 | Submission has been amended | No |
| 2014-08-01 | This submission is the final filing | No |
| 2014-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-08-01 | Plan is a collectively bargained plan | No |
| 2014-08-01 | Plan funding arrangement – Insurance | Yes |
| 2014-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: GROSVENOR PROPERTIES LTD. 2013 form 5500 responses |
|---|
| 2013-08-01 | Type of plan entity | Single employer plan |
| 2013-08-01 | Submission has been amended | No |
| 2013-08-01 | This submission is the final filing | No |
| 2013-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-08-01 | Plan is a collectively bargained plan | No |
| 2013-08-01 | Plan funding arrangement – Insurance | Yes |
| 2013-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: GROSVENOR PROPERTIES LTD. 2012 form 5500 responses |
|---|
| 2012-08-01 | Type of plan entity | Single employer plan |
| 2012-08-01 | Submission has been amended | No |
| 2012-08-01 | This submission is the final filing | No |
| 2012-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-08-01 | Plan is a collectively bargained plan | No |
| 2012-08-01 | Plan funding arrangement – Insurance | Yes |
| 2012-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: GROSVENOR PROPERTIES LTD. 2011 form 5500 responses |
|---|
| 2011-08-01 | Type of plan entity | Single employer plan |
| 2011-08-01 | Submission has been amended | No |
| 2011-08-01 | This submission is the final filing | No |
| 2011-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-08-01 | Plan is a collectively bargained plan | No |
| 2011-08-01 | Plan funding arrangement – Insurance | Yes |
| 2011-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | Submission has been amended | No |
| 2011-07-01 | This submission is the final filing | No |
| 2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2011-07-01 | Plan is a collectively bargained plan | No |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: GROSVENOR PROPERTIES LTD. 2009 form 5500 responses |
|---|
| 2009-07-01 | Type of plan entity | Single employer plan |
| 2009-07-01 | Submission has been amended | No |
| 2009-07-01 | This submission is the final filing | No |
| 2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-07-01 | Plan is a collectively bargained plan | No |
| 2009-07-01 | Plan funding arrangement – Insurance | Yes |
| 2009-07-01 | Plan benefit arrangement – Insurance | Yes |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9674037 |
| Policy instance | 4 |
| Insurance contract or identification number | 9674037 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $15 | | Total amount of fees paid to insurance company | USD $8 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $162 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 8 | | Additional information about fees paid to insurance broker | MARKETING FEE | | Insurance broker name | FLEXVISION - MD |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAXC |
| Policy instance | 3 |
| Insurance contract or identification number | G000AAXC | | Number of Individuals Covered | 27 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $513 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,052 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $513 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3334971 |
| Policy instance | 2 |
| Insurance contract or identification number | 3334971 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $295 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,969 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $295 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603673 |
| Policy instance | 1 |
| Insurance contract or identification number | 603673 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $907 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $21,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $907 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAXC |
| Policy instance | 3 |
| Insurance contract or identification number | G000AAXC | | Number of Individuals Covered | 28 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $1,720 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,879 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,720 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3334971 |
| Policy instance | 2 |
| Insurance contract or identification number | 3334971 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $1,004 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,677 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,004 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603673 |
| Policy instance | 1 |
| Insurance contract or identification number | 603673 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $4,687 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $74,965 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,687 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C. PLACAK & ASSOCIATES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9674037 |
| Policy instance | 4 |
| Insurance contract or identification number | 9674037 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $62 | | Total amount of fees paid to insurance company | USD $31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $633 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 31 | | Insurance broker organization code? | 4 | | Commission paid to Insurance Broker | USD $62 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAXC |
| Policy instance | 2 |
| Insurance contract or identification number | G000AAXC | | Number of Individuals Covered | 26 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $5,118 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $20,474 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,118 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C. PLACAK & ASSOCIATES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603673 |
| Policy instance | 3 |
| Insurance contract or identification number | 603673 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $13,024 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $215,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,024 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C. PLACAK & ASSOCIATION |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9674037 |
| Policy instance | 4 |
| Insurance contract or identification number | 9674037 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $167 | | Total amount of fees paid to insurance company | USD $83 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,816 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 83 | | Additional information about fees paid to insurance broker | MARKETING FEE | | Insurance broker organization code? | 4 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3334971 |
| Policy instance | 1 |
| Insurance contract or identification number | 3334971 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $2,523 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,929 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,523 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9674037 |
| Policy instance | 4 |
| Insurance contract or identification number | 9674037 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $175 | | Total amount of fees paid to insurance company | USD $87 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $175 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 87 | | Additional information about fees paid to insurance broker | MARKETING FEE | | Insurance broker name | FLEXVISION - MD |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAXC |
| Policy instance | 3 |
| Insurance contract or identification number | G000AAXC | | Number of Individuals Covered | 25 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $4,312 | | Total amount of fees paid to insurance company | USD $383 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,248 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,312 | | Amount paid for insurance broker fees | 383 | | Additional information about fees paid to insurance broker | BROKER OF RECORD, OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3334971 |
| Policy instance | 2 |
| Insurance contract or identification number | 3334971 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $2,213 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,858 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,213 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603673 |
| Policy instance | 1 |
| Insurance contract or identification number | 603673 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $12,935 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $200,345 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,935 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3334971 |
| Policy instance | 2 |
| Insurance contract or identification number | 3334971 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $2,519 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,927 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,519 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603673 |
| Policy instance | 1 |
| Insurance contract or identification number | 603673 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $14,163 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $216,404 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,163 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AAXC |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AAXC | | Number of Individuals Covered | 25 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $4,178 | | Total amount of fees paid to insurance company | USD $915 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,713 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,178 | | Amount paid for insurance broker fees | 915 | | Additional information about fees paid to insurance broker | BROKER OF RECORD, OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT C PLACAK & ASSOCIATES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9674037 |
| Policy instance | 4 |
| Insurance contract or identification number | 9674037 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $190 | | Total amount of fees paid to insurance company | USD $95 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $190 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 95 | | Additional information about fees paid to insurance broker | MARKETING FEE | | Insurance broker name | FLEXVISION - MD |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603673 |
| Policy instance | 1 |
| Insurance contract or identification number | 603673 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $27,173 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $373,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AAXC |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AAXC | | Number of Individuals Covered | 31 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $6,771 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,648 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3334971 |
| Policy instance | 2 |
| Insurance contract or identification number | 3334971 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $4,949 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9674037 |
| Policy instance | 4 |
| Insurance contract or identification number | 9674037 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $410 | | Total amount of fees paid to insurance company | USD $205 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9674037 |
| Policy instance | 4 |
| Insurance contract or identification number | 9674037 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $32 | | Total amount of fees paid to insurance company | USD $16 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $338 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 493451 |
| Policy instance | 2 |
| Insurance contract or identification number | 493451 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $1,633 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 351079 |
| Policy instance | 1 |
| Insurance contract or identification number | 351079 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $1,337 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,565 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AAXC |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AAXC | | Number of Individuals Covered | 56 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $484 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 493451 |
| Policy instance | 2 |
| Insurance contract or identification number | 493451 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $11,050 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $176,233 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9674037 |
| Policy instance | 4 |
| Insurance contract or identification number | 9674037 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $463 | | Total amount of fees paid to insurance company | USD $231 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,540 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AAXC |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AAXC | | Number of Individuals Covered | 54 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $6,321 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,231 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 351079 |
| Policy instance | 1 |
| Insurance contract or identification number | 351079 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $20,894 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $321,441 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
