ASPIRANET HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	ASPIRANET HEALTH AND WELFARE PLAN
Plan identification number	550

ASPIRANET HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

ASPIRANET has sponsored the creation of one or more 401k plans.

Company Name:	ASPIRANET
Employer identification number (EIN):	942442955
NAIC Classification:	624100
NAIC Description:	Individual and Family Services

Additional information about ASPIRANET

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	C0755509

More information about ASPIRANET

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ASPIRANET HEALTH AND WELFARE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
550	2021-07-01	VERNON BROWN	2022-11-15
550	2020-07-01	VERNON BROWN	2021-12-06
550	2019-07-01	VERNON BROWN	2020-12-18
550	2018-07-01	VERNON BROWN	2020-03-05
550	2017-07-01	VERNON BROWN		VERNON BROWN	2019-01-19
550	2016-07-01	VERNON BROWN		VERNON BROWN	2018-04-09
550	2015-07-01	VERNON BROWN
550	2014-07-01	VERNON BROWN
550	2013-07-01	VERNON BROWN
550	2012-07-01	VERNON BROWN
550	2012-05-01	VERNON BROWN
550	2011-05-01	VERNON BROWN
550	2010-05-01	VERNON BROWN
550	2009-05-01	VERNON BROWN

Plan Statistics for ASPIRANET HEALTH AND WELFARE PLAN

401k plan membership statisitcs for ASPIRANET HEALTH AND WELFARE PLAN

Measure	Date	Value
2021: ASPIRANET HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	741
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	828
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	828
Number of employers contributing to the scheme	2021-07-01	0
2020: ASPIRANET HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	807
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	741
Number of retired or separated participants receiving benefits	2020-07-01	0
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	741
Number of employers contributing to the scheme	2020-07-01	0
2019: ASPIRANET HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	801
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	807
Number of retired or separated participants receiving benefits	2019-07-01	0
Number of other retired or separated participants entitled to future benefits	2019-07-01	0
Total of all active and inactive participants	2019-07-01	807
Number of employers contributing to the scheme	2019-07-01	0
2018: ASPIRANET HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	677
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	801
Number of retired or separated participants receiving benefits	2018-07-01	0
Number of other retired or separated participants entitled to future benefits	2018-07-01	0
Total of all active and inactive participants	2018-07-01	801
Number of employers contributing to the scheme	2018-07-01	0
2017: ASPIRANET HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	689
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	677
Number of retired or separated participants receiving benefits	2017-07-01	4
Number of other retired or separated participants entitled to future benefits	2017-07-01	0
Total of all active and inactive participants	2017-07-01	681
2016: ASPIRANET HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	611
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	688
Number of retired or separated participants receiving benefits	2016-07-01	1
Number of other retired or separated participants entitled to future benefits	2016-07-01	0
Total of all active and inactive participants	2016-07-01	689
2015: ASPIRANET HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	579
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	582
Number of retired or separated participants receiving benefits	2015-07-01	3
Number of other retired or separated participants entitled to future benefits	2015-07-01	0
Total of all active and inactive participants	2015-07-01	585
2014: ASPIRANET HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	406
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	575
Number of retired or separated participants receiving benefits	2014-07-01	4
Number of other retired or separated participants entitled to future benefits	2014-07-01	0
Total of all active and inactive participants	2014-07-01	579
2013: ASPIRANET HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	454
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	404
Number of retired or separated participants receiving benefits	2013-07-01	2
Number of other retired or separated participants entitled to future benefits	2013-07-01	0
Total of all active and inactive participants	2013-07-01	406
2012: ASPIRANET HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	491
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	450
Number of retired or separated participants receiving benefits	2012-07-01	4
Number of other retired or separated participants entitled to future benefits	2012-07-01	0
Total of all active and inactive participants	2012-07-01	454
Total participants, beginning-of-year	2012-05-01	486
Total number of active participants reported on line 7a of the Form 5500	2012-05-01	486
Number of retired or separated participants receiving benefits	2012-05-01	5
Number of other retired or separated participants entitled to future benefits	2012-05-01	0
Total of all active and inactive participants	2012-05-01	491
2011: ASPIRANET HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-05-01	605
Total number of active participants reported on line 7a of the Form 5500	2011-05-01	486
Number of retired or separated participants receiving benefits	2011-05-01	7
Number of other retired or separated participants entitled to future benefits	2011-05-01	0
Total of all active and inactive participants	2011-05-01	493
2010: ASPIRANET HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-05-01	423
Total number of active participants reported on line 7a of the Form 5500	2010-05-01	531
Number of retired or separated participants receiving benefits	2010-05-01	13
Number of other retired or separated participants entitled to future benefits	2010-05-01	0
Total of all active and inactive participants	2010-05-01	544
2009: ASPIRANET HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-05-01	384
Total number of active participants reported on line 7a of the Form 5500	2009-05-01	413
Number of retired or separated participants receiving benefits	2009-05-01	10
Number of other retired or separated participants entitled to future benefits	2009-05-01	0
Total of all active and inactive participants	2009-05-01	423

Form 5500 Responses for ASPIRANET HEALTH AND WELFARE PLAN

2021: ASPIRANET HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2020: ASPIRANET HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: ASPIRANET HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: ASPIRANET HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: ASPIRANET HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Submission has been amended	No
2017-07-01	This submission is the final filing	No
2017-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-07-01	Plan is a collectively bargained plan	No
2017-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: ASPIRANET HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Submission has been amended	No
2016-07-01	This submission is the final filing	No
2016-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-07-01	Plan is a collectively bargained plan	No
2016-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: ASPIRANET HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Submission has been amended	No
2015-07-01	This submission is the final filing	No
2015-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-07-01	Plan is a collectively bargained plan	No
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: ASPIRANET HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Submission has been amended	No
2014-07-01	This submission is the final filing	No
2014-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-07-01	Plan is a collectively bargained plan	No
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: ASPIRANET HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Submission has been amended	No
2013-07-01	This submission is the final filing	No
2013-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-07-01	Plan is a collectively bargained plan	No
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: ASPIRANET HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Submission has been amended	No
2012-07-01	This submission is the final filing	No
2012-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-07-01	Plan is a collectively bargained plan	No
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2012-05-01	Type of plan entity	Single employer plan
2012-05-01	Submission has been amended	No
2012-05-01	This submission is the final filing	No
2012-05-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2012-05-01	Plan is a collectively bargained plan	No
2012-05-01	Plan funding arrangement – Insurance	Yes
2012-05-01	Plan benefit arrangement – Insurance	Yes
2011: ASPIRANET HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-05-01	Type of plan entity	Single employer plan
2011-05-01	Submission has been amended	No
2011-05-01	This submission is the final filing	No
2011-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-05-01	Plan is a collectively bargained plan	No
2011-05-01	Plan funding arrangement – Insurance	Yes
2011-05-01	Plan benefit arrangement – Insurance	Yes
2010: ASPIRANET HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-05-01	Type of plan entity	Single employer plan
2010-05-01	Submission has been amended	No
2010-05-01	This submission is the final filing	No
2010-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-05-01	Plan is a collectively bargained plan	No
2010-05-01	Plan funding arrangement – Insurance	Yes
2010-05-01	Plan benefit arrangement – Insurance	Yes
2009: ASPIRANET HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-05-01	Type of plan entity	Single employer plan
2009-05-01	Submission has been amended	No
2009-05-01	This submission is the final filing	No
2009-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-05-01	Plan is a collectively bargained plan	No
2009-05-01	Plan funding arrangement – Insurance	Yes
2009-05-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	165844
Policy instance	1
Insurance contract or identification number 165844 Number of Individuals Covered 828 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $103,396 Total amount of fees paid to insurance company USD $11,516 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $2,881,216 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $103,396 Amount paid for insurance broker fees 11516 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number	659309
Policy instance	2
Insurance contract or identification number 659309 Number of Individuals Covered 104 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $3,786 Total amount of fees paid to insurance company USD $189 Other welfare benefits provided CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $25,265 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,786 Amount paid for insurance broker fees 189 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
HEALTHIEST YOU (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	HNMD00150
Policy instance	3
Insurance contract or identification number HNMD00150 Number of Individuals Covered 700 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $7,377 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided TELEMEDICINE Welfare Benefit Premiums Paid to Carrier USD $49,182 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,377 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	4
Insurance contract or identification number 15186 Number of Individuals Covered 145 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $64,268 Total amount of fees paid to insurance company USD $666 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 Welfare Benefit Premiums Paid to Carrier USD $1,251,536 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $64,268 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker BONUS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0743781
Policy instance	5
Insurance contract or identification number R0743781 Number of Individuals Covered 415 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $44,767 Total amount of fees paid to insurance company USD $3,398 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $242,779 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $43,923 Amount paid for insurance broker fees 3398 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0743781
Policy instance	6
Insurance contract or identification number R0743781 Number of Individuals Covered 346 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $39,595 Total amount of fees paid to insurance company USD $2,962 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $213,485 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $131 Amount paid for insurance broker fees 5 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	65516
Policy instance	2
Insurance contract or identification number 65516 Number of Individuals Covered 741 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $15,010 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	5
Insurance contract or identification number 15186 Number of Individuals Covered 232 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $70,338 Total amount of fees paid to insurance company USD $648 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 Welfare Benefit Premiums Paid to Carrier USD $1,333,221 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $47,563 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker BONUS
HEALTHIEST YOU (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	HNMD00150
Policy instance	4
Insurance contract or identification number HNMD00150 Number of Individuals Covered 75 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $1,829 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided TELEMEDICINE Welfare Benefit Premiums Paid to Carrier USD $12,194 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,829 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number	659309
Policy instance	3
Insurance contract or identification number 659309 Number of Individuals Covered 102 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $8,550 Total amount of fees paid to insurance company USD $561 Other welfare benefits provided CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $22,573 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,550 Amount paid for insurance broker fees 561 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	165844
Policy instance	1
Insurance contract or identification number 165844 Number of Individuals Covered 976 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $117,696 Total amount of fees paid to insurance company USD $9,415 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $2,571,578 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $117,699 Amount paid for insurance broker fees 9415 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number	659309
Policy instance	3
Insurance contract or identification number 659309 Number of Individuals Covered 132 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $2,368 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $28,024 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,368 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HEALTHIEST YOU (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	HNMD00150
Policy instance	4
Insurance contract or identification number HNMD00150 Number of Individuals Covered 60 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $1,306 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided TELEMEDICINE Welfare Benefit Premiums Paid to Carrier USD $8,708 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,306 Insurance broker organization code? 3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	165844
Policy instance	1
Insurance contract or identification number 165844 Number of Individuals Covered 1081 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $132,660 Total amount of fees paid to insurance company USD $6,093 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $2,989,793 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $133,108 Amount paid for insurance broker fees 6093 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	6
Insurance contract or identification number 15186 Number of Individuals Covered 245 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $65,861 Total amount of fees paid to insurance company USD $0 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 Welfare Benefit Premiums Paid to Carrier USD $1,343,509 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $42,567 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	65516
Policy instance	2
Insurance contract or identification number 65516 Number of Individuals Covered 807 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $15,536 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0743781
Policy instance	5
Insurance contract or identification number R0743781 Number of Individuals Covered 370 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $45,095 Total amount of fees paid to insurance company USD $3,847 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $168,891 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,719 Amount paid for insurance broker fees 1809 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	5
Insurance contract or identification number 15186 Number of Individuals Covered 189 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $64,524 Total amount of fees paid to insurance company USD $1 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 Welfare Benefit Premiums Paid to Carrier USD $1,283,013 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $41,050 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	65516
Policy instance	2
Insurance contract or identification number 65516 Number of Individuals Covered 801 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $14,371 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HEALTHIEST YOU (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	HNMD00150
Policy instance	4
Insurance contract or identification number HNMD00150 Number of Individuals Covered 40 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $845 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided TELEMEDICINE Welfare Benefit Premiums Paid to Carrier USD $5,634 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $493 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number	659309
Policy instance	3
Insurance contract or identification number 659309 Number of Individuals Covered 129 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $20,829 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	165844
Policy instance	1
Insurance contract or identification number 165844 Number of Individuals Covered 1094 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $160,505 Total amount of fees paid to insurance company USD $7,498 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $3,218,075 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $95,918 Amount paid for insurance broker fees 7498 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0743781
Policy instance	6
Insurance contract or identification number R0743781 Number of Individuals Covered 205 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $32,585 Total amount of fees paid to insurance company USD $626 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $211,278 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $26,952 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	34/5427344
Policy instance	11
Insurance contract or identification number 34/5427344 Number of Individuals Covered 65 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $5,920 Total amount of fees paid to insurance company USD $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 plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit 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 $39,465 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,920 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5427345
Policy instance	5
Insurance contract or identification number 5427345 Number of Individuals Covered 347 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $11,346 Total amount of fees paid to insurance company USD $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 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $75,664 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,346 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	1
Insurance contract or identification number 15186 Number of Individuals Covered 76 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $23,437 Total amount of fees paid to insurance company USD $1 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 $509,686 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,437 Amount paid for insurance broker fees 1 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229235
Policy instance	2
Insurance contract or identification number 229235 Number of Individuals Covered 86 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $28,299 Total amount of fees paid to insurance company USD $1 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 $618,302 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,299 Amount paid for insurance broker fees 1 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	38865
Policy instance	3
Insurance contract or identification number 38865 Number of Individuals Covered 10 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 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 No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER 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 $1,189 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	8002065
Policy instance	4
Insurance contract or identification number 8002065 Number of Individuals Covered 65 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $6,540 Total amount of fees paid to insurance company USD $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 plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CRITICAL ILLNESS 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 $16,435 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,540 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	65516
Policy instance	6
Insurance contract or identification number 65516 Number of Individuals Covered 739 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 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 No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,386 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	8001269
Policy instance	7
Insurance contract or identification number 8001269 Number of Individuals Covered 66 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $6,295 Total amount of fees paid to insurance company USD $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 plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,852 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,295 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	1281
Policy instance	9
Insurance contract or identification number 1281 Number of Individuals Covered 116 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $16,385 Total amount of fees paid to insurance company USD $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 plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $44,712 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,385 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	165844
Policy instance	10
Insurance contract or identification number 165844 Number of Individuals Covered 718 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $3,807 Total amount of fees paid to insurance company USD $207 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 Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $81,899 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,807 Amount paid for insurance broker fees 207 Additional information about fees paid to insurance broker OTHER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	165844
Policy instance	8
Insurance contract or identification number 165844 Number of Individuals Covered 668 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $132,199 Total amount of fees paid to insurance company USD $7,196 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 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 $2,843,867 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $132,199 Amount paid for insurance broker fees 7196 Additional information about fees paid to insurance broker OTHER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	165844
Policy instance	6
Insurance contract or identification number 165844 Number of Individuals Covered 316 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $3,566 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $41,394 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,566 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number	5427345
Policy instance	7
Insurance contract or identification number 5427345 Number of Individuals Covered 207 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $3,703 Total amount of fees paid to insurance company USD $796 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 $37,030 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,703 Amount paid for insurance broker fees 796 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	38865
Policy instance	8
Insurance contract or identification number 38865 Number of Individuals Covered 12 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER 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 $1,658 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	34/5427344
Policy instance	9
Insurance contract or identification number 34/5427344 Number of Individuals Covered 41 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $4,497 Total amount of fees paid to insurance company USD $1,230 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No 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 $29,980 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,497 Amount paid for insurance broker fees 1230 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	836230
Policy instance	10
Insurance contract or identification number 836230 Number of Individuals Covered 597 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,443 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	8001269
Policy instance	11
Insurance contract or identification number 8001269 Number of Individuals Covered 21 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $2,748 Total amount of fees paid to insurance company USD $206 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENT 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 $4,934 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,748 Amount paid for insurance broker fees 206 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	12
Insurance contract or identification number 15186 Number of Individuals Covered 55 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $21,413 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 $395,638 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,413 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	847166
Policy instance	13
Insurance contract or identification number 847166 Number of Individuals Covered 424 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $92,819 Total amount of fees paid to insurance company USD $66 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,031,945 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $92,819 Amount paid for insurance broker fees 66 Additional information about fees paid to insurance broker INDIRECT COMPENSATION Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5427345
Policy instance	5
Insurance contract or identification number 5427345 Number of Individuals Covered 259 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $8,431 Total amount of fees paid to insurance company USD $2,445 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $59,428 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,431 Amount paid for insurance broker fees 2445 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	8002065
Policy instance	3
Insurance contract or identification number 8002065 Number of Individuals Covered 16 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $2,686 Total amount of fees paid to insurance company USD $179 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CRITICAL ILLNESS 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 $4,721 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,686 Amount paid for insurance broker fees 179 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229235
Policy instance	2
Insurance contract or identification number 229235 Number of Individuals Covered 63 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $25,058 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 $470,961 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,058 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	1281
Policy instance	1
Insurance contract or identification number 1281 Number of Individuals Covered 53 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $11,562 Total amount of fees paid to insurance company USD $848 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $19,671 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,562 Amount paid for insurance broker fees 848 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	847166HNO
Policy instance	4
Insurance contract or identification number 847166HNO Number of Individuals Covered 18 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $8,208 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 $182,137 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,208 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	34/5427344
Policy instance	8
Insurance contract or identification number 34/5427344 Number of Individuals Covered 40 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $3,773 Total amount of fees paid to insurance company USD $15 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit 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 $25,151 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,773 Amount paid for insurance broker fees 15 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229235
Policy instance	5
Insurance contract or identification number 229235 Number of Individuals Covered 62 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $20,688 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 $422,889 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,688 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	836230
Policy instance	3
Insurance contract or identification number 836230 Number of Individuals Covered 577 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,688 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	847166HNO
Policy instance	2
Insurance contract or identification number 847166HNO Number of Individuals Covered 17 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $6,080 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 $147,453 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,080 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	1
Insurance contract or identification number 15186 Number of Individuals Covered 66 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $19,588 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 $395,832 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,342 Insurance broker organization code? 3 Insurance broker name ASCENSION BENEFITS & INSURANCE
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	38865
Policy instance	4
Insurance contract or identification number 38865 Number of Individuals Covered 15 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER 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 $2,283 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	847166
Policy instance	6
Insurance contract or identification number 847166 Number of Individuals Covered 418 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $76,321 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 Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,839,938 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $76,321 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	Q0227
Policy instance	7
Insurance contract or identification number Q0227 Number of Individuals Covered 5 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $691 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 Other welfare benefits provided ACCIDENT AND CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,111 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $691 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	30/5464082
Policy instance	9
Insurance contract or identification number 30/5464082 Number of Individuals Covered 35 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $3,699 Total amount of fees paid to insurance company USD $15 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $24,731 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,699 Amount paid for insurance broker fees 15 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number	5427345
Policy instance	10
Insurance contract or identification number 5427345 Number of Individuals Covered 212 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $3,793 Total amount of fees paid to insurance company USD $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 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 $37,930 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,793 Amount paid for insurance broker fees 23 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	165844
Policy instance	11
Insurance contract or identification number 165844 Number of Individuals Covered 317 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $9,674 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $36,810 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,674 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5427345
Policy instance	12
Insurance contract or identification number 5427345 Number of Individuals Covered 245 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $7,967 Total amount of fees paid to insurance company USD $28 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $56,455 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,967 Amount paid for insurance broker fees 28 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12166015
Policy instance	6
Insurance contract or identification number 12166015 Number of Individuals Covered 57 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $239 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,712 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $239 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	836230
Policy instance	5
Insurance contract or identification number 836230 Number of Individuals Covered 512 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,701 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	34/5427344
Policy instance	4
Insurance contract or identification number 34/5427344 Number of Individuals Covered 40 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $4,124 Total amount of fees paid to insurance company USD $549 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit 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 $27,495 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,399 Amount paid for insurance broker fees 549 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	165844
Policy instance	3
Insurance contract or identification number 165844 Number of Individuals Covered 285 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $80,328 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,740,143 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $73,273 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	38865
Policy instance	7
Insurance contract or identification number 38865 Number of Individuals Covered 21 Insurance policy start date 2014-05-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,109 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number	5427345
Policy instance	8
Insurance contract or identification number 5427345 Number of Individuals Covered 159 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $3,029 Total amount of fees paid to insurance company USD $301 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 $30,296 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,526 Amount paid for insurance broker fees 301 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	30/5464082
Policy instance	9
Insurance contract or identification number 30/5464082 Number of Individuals Covered 31 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $3,547 Total amount of fees paid to insurance company USD $482 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $23,649 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,981 Amount paid for insurance broker fees 482 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	10
Insurance contract or identification number 15186 Number of Individuals Covered 50 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $17,053 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 $339,061 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,741 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229235
Policy instance	11
Insurance contract or identification number 229235 Number of Individuals Covered 55 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $19,244 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 $377,130 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,489 Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5427345
Policy instance	2
Insurance contract or identification number 5427345 Number of Individuals Covered 139 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $5,523 Total amount of fees paid to insurance company USD $734 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $37,579 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,586 Amount paid for insurance broker fees 734 Additional information about fees paid to insurance broker BROKER FEES Insurance broker organization code? 3 Insurance broker name HEFFERNAN INSURANCE BROKERS
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	38865
Policy instance	1
Insurance contract or identification number 38865 Number of Individuals Covered 21 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,397 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	38865
Policy instance	7
Insurance contract or identification number 38865 Number of Individuals Covered 22 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,308 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12166015
Policy instance	8
Insurance contract or identification number 12166015 Number of Individuals Covered 53 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $884 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,678 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $884 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	11463000
Policy instance	6
Insurance contract or identification number 11463000 Number of Individuals Covered 16 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $2,174 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 Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,593 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,174 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY, INC.
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	836230
Policy instance	5
Insurance contract or identification number 836230 Number of Individuals Covered 489 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,593 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5427345
Policy instance	4
Insurance contract or identification number 5427345 Number of Individuals Covered 121 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $9,803 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $65,982 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,803 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY, INC.
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number	5427345
Policy instance	3
Insurance contract or identification number 5427345 Number of Individuals Covered 164 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $3,028 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 $30,278 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,028 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	165844
Policy instance	2
Insurance contract or identification number 165844 Number of Individuals Covered 333 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $72,656 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,584,637 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $72,656 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229235/15186
Policy instance	1
Insurance contract or identification number 229235/15186 Number of Individuals Covered 118 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $35,570 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 $778,644 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35,570 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY, INC.
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	34 5427344
Policy instance	9
Insurance contract or identification number 34 5427344 Number of Individuals Covered 51 Insurance policy start date 2012-05-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $550 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit 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 $3,665 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $550 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	165844
Policy instance	8
Insurance contract or identification number 165844 Number of Individuals Covered 223 Insurance policy start date 2012-05-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $10,858 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes 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 $223,462 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $149 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY INC
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	836230
Policy instance	7
Insurance contract or identification number 836230 Number of Individuals Covered 459 Insurance policy start date 2012-05-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EAP 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 $588 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	38865
Policy instance	6
Insurance contract or identification number 38865 Number of Individuals Covered 23 Insurance policy start date 2012-05-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER 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 $4,593 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	89476
Policy instance	5
Insurance contract or identification number 89476 Number of Individuals Covered 13 Insurance policy start date 2012-05-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $326 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,256 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $326 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	4
Insurance contract or identification number 15186 Number of Individuals Covered 62 Insurance policy start date 2012-05-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $3,072 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 $60,917 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,072 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY, INC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229235
Policy instance	3
Insurance contract or identification number 229235 Number of Individuals Covered 63 Insurance policy start date 2012-05-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $3,114 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 $59,350 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,114 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY, INC
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number	5427345
Policy instance	2
Insurance contract or identification number 5427345 Number of Individuals Covered 168 Insurance policy start date 2012-05-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $511 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 $5,115 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $511 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5427345
Policy instance	1
Insurance contract or identification number 5427345 Number of Individuals Covered 116 Insurance policy start date 2012-05-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $1,507 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD & D, VOLUNTARY LIFE AND 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 Carrier USD $10,150 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,507 Insurance broker organization code? 3 Insurance broker name PORTAL INSURANCE AGENCY
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5427345
Policy instance	8
Insurance contract or identification number 5427345 Number of Individuals Covered 122 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $10,059 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD & D, VOLUNTARY LIFE AND 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 Carrier USD $67,651 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	165844
Policy instance	2
Insurance contract or identification number 165844 Number of Individuals Covered 225 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $68,373 Total amount of fees paid to insurance company USD $4,012 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes 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 $1,447,265 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	836230
Policy instance	3
Insurance contract or identification number 836230 Number of Individuals Covered 460 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,045 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	4
Insurance contract or identification number 15186 Number of Individuals Covered 65 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $28,290 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 $448,695 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229235
Policy instance	5
Insurance contract or identification number 229235 Number of Individuals Covered 61 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $19,705 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 $363,034 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	89476
Policy instance	6
Insurance contract or identification number 89476 Number of Individuals Covered 15 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $1,923 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $19,225 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number	5427345
Policy instance	7
Insurance contract or identification number 5427345 Number of Individuals Covered 175 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $3,037 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 $30,460 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	34 5427344
Policy instance	9
Insurance contract or identification number 34 5427344 Number of Individuals Covered 51 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $3,173 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit 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 $21,156 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	38865
Policy instance	1
Insurance contract or identification number 38865 Number of Individuals Covered 25 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER 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 $4,939 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229235
Policy instance	1
Insurance contract or identification number 229235 Number of Individuals Covered 57 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $16,438 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 $342,303 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	89476
Policy instance	10
Insurance contract or identification number 89476 Number of Individuals Covered 2 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $437 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,371 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	836230
Policy instance	9
Insurance contract or identification number 836230 Number of Individuals Covered 466 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,700 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	CANCER
Policy instance	8
Insurance contract or identification number CANCER Number of Individuals Covered 18 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER 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 $6,096 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	165844
Policy instance	7
Insurance contract or identification number 165844 Number of Individuals Covered 531 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $1,734 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $40,200 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	165844
Policy instance	6
Insurance contract or identification number 165844 Number of Individuals Covered 235 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $61,186 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,418,842 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number	5427345
Policy instance	5
Insurance contract or identification number 5427345 Number of Individuals Covered 189 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $3,412 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 $34,140 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	15186
Policy instance	4
Insurance contract or identification number 15186 Number of Individuals Covered 75 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $24,274 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 $512,919 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5427345
Policy instance	3
Insurance contract or identification number 5427345 Number of Individuals Covered 119 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $11,162 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $75,117 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5427344
Policy instance	2
Insurance contract or identification number 5427344 Number of Individuals Covered 47 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $3,222 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit 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 $21,480 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No