ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN
Plan identification number	510

ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS 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) Prepaid legal Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

ARCATA ASSOCIATES, INC. has sponsored the creation of one or more 401k plans.

Company Name:	ARCATA ASSOCIATES, INC.
Employer identification number (EIN):	942511090
NAIC Classification:	541330
NAIC Description:	Engineering Services

Additional information about ARCATA ASSOCIATES, INC.

Jurisdiction of Incorporation:	Nevada Department of State
Incorporation Date:	1995-02-10
Company Identification Number:	19951052852
Legal Registered Office Address:	2588 FIRE MESA ST STE 110 LAS VEGAS United States of America (USA) 89128

More information about ARCATA ASSOCIATES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
510	2022-01-01	CHRIS HIGGINS	2023-06-08
510	2021-01-01	CHRIS HIGGINS	2022-07-08
510	2020-01-01	CHRIS HIGGINS	2021-07-27
510	2019-01-01	CHRIS HIGGINS	2020-07-28
510	2018-01-01
510	2017-01-01
510	2016-01-01	CONNIE MOORE
510	2015-01-01	CONNIE MOORE
510	2014-01-01	CONNIE MOORE
510	2013-01-01	CONNIE MOORE
510	2012-01-01	CONNIE MOORE
510	2011-01-01	NANCY C. WONG
510	2010-01-01	NANCY C. WONG
510	2009-01-01	NANCY C. WONG

Plan Statistics for ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN

Measure	Date	Value
2022: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	475
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	474
Number of retired or separated participants receiving benefits	2022-01-01	3
Number of other retired or separated participants entitled to future benefits	2022-01-01	10
Total of all active and inactive participants	2022-01-01	487
Number of employers contributing to the scheme	2022-01-01	0
2021: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	339
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	475
Number of retired or separated participants receiving benefits	2021-01-01	3
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	478
Number of employers contributing to the scheme	2021-01-01	0
2020: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	350
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	336
Number of retired or separated participants receiving benefits	2020-01-01	3
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	339
Number of employers contributing to the scheme	2020-01-01	0
2019: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	447
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	347
Number of retired or separated participants receiving benefits	2019-01-01	3
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	350
Number of employers contributing to the scheme	2019-01-01	0
2018: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	366
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	447
Number of retired or separated participants receiving benefits	2018-01-01	1
Number of other retired or separated participants entitled to future benefits	2018-01-01	3
Total of all active and inactive participants	2018-01-01	451
Number of employers contributing to the scheme	2018-01-01	0
2017: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	316
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	364
Number of retired or separated participants receiving benefits	2017-01-01	2
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	366
2016: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	297
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	315
Number of retired or separated participants receiving benefits	2016-01-01	1
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	316
2015: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	347
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	297
Number of retired or separated participants receiving benefits	2015-01-01	6
Number of other retired or separated participants entitled to future benefits	2015-01-01	6
Total of all active and inactive participants	2015-01-01	309
2014: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	410
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	318
Number of retired or separated participants receiving benefits	2014-01-01	9
Number of other retired or separated participants entitled to future benefits	2014-01-01	19
Total of all active and inactive participants	2014-01-01	346
2013: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	412
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	406
Number of retired or separated participants receiving benefits	2013-01-01	4
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	410
2012: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	403
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	412
Number of retired or separated participants receiving benefits	2012-01-01	6
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	418
2011: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	416
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	403
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	403
2010: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	435
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	417
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	417
2009: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	415
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	421
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	421

Form 5500 Responses for ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN

2022: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: ARCATA ASSOCIATES, INC. EMPLOYEE BENEFITS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3339976
Policy instance	3
Insurance contract or identification number 3339976 Number of Individuals Covered 261 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $12,837 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $259,048 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,837 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12220855
Policy instance	1
Insurance contract or identification number 12220855 Number of Individuals Covered 231 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,454 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $38,013 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,454 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	2
Insurance contract or identification number 10001229 Number of Individuals Covered 247 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $70,433 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,451,036 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $70,433 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967433
Policy instance	10
Insurance contract or identification number FLX967433 Number of Individuals Covered 474 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $719 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $291,063 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 719 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090417
Policy instance	4
Insurance contract or identification number 6090417 Number of Individuals Covered 78 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $2,073 Total amount of fees paid to insurance company USD $411 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $19,208 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,073 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00
Policy instance	5
Insurance contract or identification number 00 Number of Individuals Covered 475 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 $6,468 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	6
Insurance contract or identification number 30339 Number of Individuals Covered 19 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	887827G
Policy instance	7
Insurance contract or identification number 887827G Number of Individuals Covered 86 Insurance policy start date 2021-06-01 Insurance policy end date 2022-05-31 Total amount of commissions paid to insurance broker USD $11,420 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $103,497 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,420 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	229264
Policy instance	8
Insurance contract or identification number 229264 Number of Individuals Covered 31 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $9,709 Total amount of fees paid to insurance company USD $204 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $212,689 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,709 Amount paid for insurance broker fees 204 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HEALTHJOY, LLC (National Association of Insurance Commissioners NAIC id number: 51121 )
Policy contract number	000
Policy instance	9
Insurance contract or identification number 000 Number of Individuals Covered 364 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided TELEHEALTH Welfare Benefit Premiums Paid to Carrier USD $11,642 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: 53031 )
Policy contract number	12220855
Policy instance	1
Insurance contract or identification number 12220855 Number of Individuals Covered 247 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,665 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $41,387 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,665 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	2
Insurance contract or identification number 10001229 Number of Individuals Covered 266 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $58,388 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,298,751 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $58,388 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3339976
Policy instance	3
Insurance contract or identification number 3339976 Number of Individuals Covered 275 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $13,341 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $269,185 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,341 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090417
Policy instance	4
Insurance contract or identification number 6090417 Number of Individuals Covered 84 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $2,020 Total amount of fees paid to insurance company USD $241 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $23,771 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,700 Amount paid for insurance broker fees 218 Additional information about fees paid to insurance broker NON-MONETARY AND SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	6
Insurance contract or identification number 30339 Number of Individuals Covered 27 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	887827G
Policy instance	7
Insurance contract or identification number 887827G Number of Individuals Covered 88 Insurance policy start date 2020-06-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $11,002 Total amount of fees paid to insurance company USD $1,016 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $99,102 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,002 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker FEES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229264
Policy instance	8
Insurance contract or identification number 229264 Number of Individuals Covered 33 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $11,626 Total amount of fees paid to insurance company USD $93 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $214,682 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,626 Amount paid for insurance broker fees 93 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967433
Policy instance	9
Insurance contract or identification number FLX967433 Number of Individuals Covered 475 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $4,310 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $297,852 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 4310 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00
Policy instance	5
Insurance contract or identification number 00 Number of Individuals Covered 475 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 $6,327 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: 53031 )
Policy contract number	12220855
Policy instance	1
Insurance contract or identification number 12220855 Number of Individuals Covered 253 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,671 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $41,759 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,671 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK968944
Policy instance	6
Insurance contract or identification number OK968944 Number of Individuals Covered 336 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $2,137 Total amount of fees paid to insurance company USD $651 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $36,133 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $2,137 Amount paid for insurance broker fees 651 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	887827
Policy instance	12
Insurance contract or identification number 887827 Number of Individuals Covered 87 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $10,521 Total amount of fees paid to insurance company USD $5,235 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $100,257 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,521 Amount paid for insurance broker fees 5235 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3339976
Policy instance	4
Insurance contract or identification number 3339976 Number of Individuals Covered 287 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $12,250 Total amount of fees paid to insurance company USD $1,108 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $247,246 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,250 Amount paid for insurance broker fees 1108 Additional information about fees paid to insurance broker GENERAL AGENT PAYMENTS Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229264
Policy instance	3
Insurance contract or identification number 229264 Number of Individuals Covered 35 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $9,894 Total amount of fees paid to insurance company USD $372 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $212,384 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,894 Amount paid for insurance broker fees 372 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	2
Insurance contract or identification number 10001229 Number of Individuals Covered 263 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $59,895 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,316,598 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $59,895 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK752041
Policy instance	7
Insurance contract or identification number LK752041 Number of Individuals Covered 336 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,837 Total amount of fees paid to insurance company USD $1,121 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $58,009 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $3,837 Amount paid for insurance broker fees 1121 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK965095
Policy instance	8
Insurance contract or identification number LK965095 Number of Individuals Covered 336 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $4,303 Total amount of fees paid to insurance company USD $1,149 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $72,274 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $4,303 Amount paid for insurance broker fees 1149 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967433
Policy instance	5
Insurance contract or identification number FLX967433 Number of Individuals Covered 336 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $7,344 Total amount of fees paid to insurance company USD $1,974 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $73,435 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $7,344 Amount paid for insurance broker fees 1974 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229264
Policy instance	14
Insurance contract or identification number 229264 Number of Individuals Covered 34 Insurance policy start date 2020-08-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $4,376 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $91,622 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,376 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	887827
Policy instance	13
Insurance contract or identification number 887827 Number of Individuals Covered 88 Insurance policy start date 2020-05-01 Insurance policy end date 2020-05-31 Total amount of commissions paid to insurance broker USD $455 Total amount of fees paid to insurance company USD $95 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $455 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker FEES
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	11
Insurance contract or identification number 30339 Number of Individuals Covered 21 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00
Policy instance	10
Insurance contract or identification number 00 Number of Individuals Covered 475 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 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 $5,998 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090417
Policy instance	9
Insurance contract or identification number 6090417 Number of Individuals Covered 82 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,966 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $16,419 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,966 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	6
Insurance contract or identification number 30339 Number of Individuals Covered 19 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00
Policy instance	5
Insurance contract or identification number 00 Number of Individuals Covered 506 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 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 $6,812 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090417
Policy instance	4
Insurance contract or identification number 6090417 Number of Individuals Covered 94 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $2,340 Total amount of fees paid to insurance company USD $41 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $23,400 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,340 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229264
Policy instance	3
Insurance contract or identification number 229264 Number of Individuals Covered 26 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $7,668 Total amount of fees paid to insurance company USD $382 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $153,794 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,668 Amount paid for insurance broker fees 382 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	2
Insurance contract or identification number 10001229 Number of Individuals Covered 272 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $38,218 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,284,460 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $38,218 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12220855
Policy instance	1
Insurance contract or identification number 12220855 Number of Individuals Covered 280 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $1,754 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $45,101 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,754 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12220855
Policy instance	7
Insurance contract or identification number 12220855 Number of Individuals Covered 263 Insurance policy start date 2019-08-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $989 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $17,977 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $989 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	8
Insurance contract or identification number 10001229 Number of Individuals Covered 281 Insurance policy start date 2019-08-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $24,604 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $595,113 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $24,604 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	SA386006710301
Policy instance	14
Insurance contract or identification number SA386006710301 Number of Individuals Covered 60 Insurance policy start date 2019-01-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $2,221 Total amount of fees paid to insurance company USD $1,080 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 Welfare Benefit Premiums Paid to Carrier USD $18,023 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,221 Amount paid for insurance broker fees 1080 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	MP0000817908
Policy instance	13
Insurance contract or identification number MP0000817908 Number of Individuals Covered 18 Insurance policy start date 2019-01-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $214 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit 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,ACCIDENT,HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $1,427 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $214 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3339976
Policy instance	12
Insurance contract or identification number 3339976 Number of Individuals Covered 315 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $76,095 Total amount of fees paid to insurance company USD $0 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 Welfare Benefit Premiums Paid to Carrier USD $709,049 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $76,095 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3339976
Policy instance	11
Insurance contract or identification number 3339976 Number of Individuals Covered 303 Insurance policy start date 2019-08-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $34,441 Total amount of fees paid to insurance company USD $3,864 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 Welfare Benefit Premiums Paid to Carrier USD $194,173 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $28,695 Amount paid for insurance broker fees 3864 Additional information about fees paid to insurance broker INCENTIVE COMPENSATION Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967433
Policy instance	10
Insurance contract or identification number FLX967433 Number of Individuals Covered 347 Insurance policy start date 2019-08-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $10,060 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $100,599 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $10,060 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967433
Policy instance	9
Insurance contract or identification number FLX967433 Number of Individuals Covered 347 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $26,588 Total amount of fees paid to insurance company USD $2,394 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 Welfare Benefit Premiums Paid to Carrier USD $265,885 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $26,588 Amount paid for insurance broker fees 2394 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	2
Insurance contract or identification number 10001229 Number of Individuals Covered 255 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $32,051 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,087,610 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $32,051 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	229264
Policy instance	3
Insurance contract or identification number 229264 Number of Individuals Covered 27 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $7,664 Total amount of fees paid to insurance company USD $455 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $154,242 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,664 Amount paid for insurance broker fees 455 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090417
Policy instance	4
Insurance contract or identification number 6090417 Number of Individuals Covered 105 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $2,399 Total amount of fees paid to insurance company USD $60 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $23,966 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,399 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00
Policy instance	5
Insurance contract or identification number 00 Number of Individuals Covered 498 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 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 $6,684 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	6
Insurance contract or identification number 30339 Number of Individuals Covered 18 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	902546
Policy instance	7
Insurance contract or identification number 902546 Number of Individuals Covered 272 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $63,945 Total amount of fees paid to insurance company USD $9,866 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,568,711 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $63,945 Amount paid for insurance broker fees 9866 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3339976
Policy instance	8
Insurance contract or identification number 3339976 Number of Individuals Covered 329 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $30,865 Total amount of fees paid to insurance company USD $1,971 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 Welfare Benefit Premiums Paid to Carrier USD $408,833 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,865 Amount paid for insurance broker fees 1971 Additional information about fees paid to insurance broker SERVICE/GENERAL AGENT PAYMENTS Insurance broker organization code? 3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	GF386006710301
Policy instance	9
Insurance contract or identification number GF386006710301 Number of Individuals Covered 50 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $6,214 Total amount of fees paid to insurance company USD $1,594 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,CRITICAL ILLNESS,ACCIDENT,HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $62,051 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,214 Amount paid for insurance broker fees 1594 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967433
Policy instance	10
Insurance contract or identification number FLX967433 Number of Individuals Covered 447 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $25,831 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $258,306 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $25,831 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12220855
Policy instance	1
Insurance contract or identification number 12220855 Number of Individuals Covered 286 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $42,445 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967433
Policy instance	10
Insurance contract or identification number FLX967433 Number of Individuals Covered 364 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $21,351 Total amount of fees paid to insurance company USD $7,390 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 Welfare Benefit Premiums Paid to Carrier USD $213,510 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $21,351 Amount paid for insurance broker fees 7390 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	9
Insurance contract or identification number 30339 Number of Individuals Covered 20 Insurance policy start date 2017-01-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $60,922 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: 53031 )
Policy contract number	12220855
Policy instance	1
Insurance contract or identification number 12220855 Number of Individuals Covered 253 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $1,579 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $37,476 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,579 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	902546
Policy instance	2
Insurance contract or identification number 902546 Number of Individuals Covered 226 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $42,129 Total amount of fees paid to insurance company USD $12,761 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,297,741 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $42,129 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker BONUS Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	3
Insurance contract or identification number 10001229 Number of Individuals Covered 252 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $29,430 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $983,646 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $29,430 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229264
Policy instance	4
Insurance contract or identification number 229264 Number of Individuals Covered 29 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $7,676 Total amount of fees paid to insurance company USD $608 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $141,342 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,676 Amount paid for insurance broker fees 608 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	5
Insurance contract or identification number 30339 Number of Individuals Covered 27 Insurance policy start date 2017-08-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3339976
Policy instance	6
Insurance contract or identification number 3339976 Number of Individuals Covered 329 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $7,566 Total amount of fees paid to insurance company USD $1,971 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $254,895 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,566 Amount paid for insurance broker fees 1971 Additional information about fees paid to insurance broker SERVICE/GENERAL AGENT PAYMENTS Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090417
Policy instance	7
Insurance contract or identification number 6090417 Number of Individuals Covered 98 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,782 Total amount of fees paid to insurance company USD $57 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $17,823 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,782 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker FEES Insurance broker name WELLS FARGO INSURANCE
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00
Policy instance	8
Insurance contract or identification number 00 Number of Individuals Covered 315 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 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 $4,234 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	902546
Policy instance	8
Insurance contract or identification number 902546 Number of Individuals Covered 106 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $57,889 Total amount of fees paid to insurance company USD $5,243 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 $1,269,094 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $57,889 Insurance broker organization code? 3 Amount paid for insurance broker fees 5243 Additional information about fees paid to insurance broker BONUS Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090417
Policy instance	7
Insurance contract or identification number 6090417 Number of Individuals Covered 55 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $1,367 Total amount of fees paid to insurance company USD $27 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 LEGAL 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 $13,670 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,367 Insurance broker organization code? 3 Amount paid for insurance broker fees 27 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker name
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	853837G
Policy instance	6
Insurance contract or identification number 853837G Number of Individuals Covered 310 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $22,211 Total amount of fees paid to insurance company USD $804 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 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 $226,153 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,972 Amount paid for insurance broker fees 804 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	1
Insurance contract or identification number 10001229 Number of Individuals Covered 238 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $25,526 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 $832,384 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $25,526 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	114732
Policy instance	4
Insurance contract or identification number 114732 Number of Individuals Covered 663 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $10,780 Total amount of fees paid to insurance company USD $2,350 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 $207,967 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,780 Amount paid for insurance broker fees 2350 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	3
Insurance contract or identification number 30339 Number of Individuals Covered 21 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 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 $104,004 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: 53031 )
Policy contract number	12220855
Policy instance	5
Insurance contract or identification number 12220855 Number of Individuals Covered 239 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $1,595 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 $39,616 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,595 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229264
Policy instance	2
Insurance contract or identification number 229264 Number of Individuals Covered 30 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $4,164 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 $248,618 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,314 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090417
Policy instance	8
Insurance contract or identification number 6090417 Number of Individuals Covered 63 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $1,739 Total amount of fees paid to insurance company USD $150 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 LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,394 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,028 Insurance broker organization code? 3 Amount paid for insurance broker fees 107 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker name WELLS FARGO INSURANCE SERVICES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229264
Policy instance	7
Insurance contract or identification number 229264 Number of Individuals Covered 70 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $15,062 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 $300,949 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,062 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	151928
Policy instance	5
Insurance contract or identification number 151928 Number of Individuals Covered 318 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $31,584 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,406,910 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $31,584 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	114732
Policy instance	6
Insurance contract or identification number 114732 Number of Individuals Covered 747 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $16,464 Total amount of fees paid to insurance company USD $4,939 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 $327,214 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,464 Insurance broker organization code? 3 Amount paid for insurance broker fees 4939 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker name WELLS FARGO INSURANCE SERVICES
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	853837G
Policy instance	4
Insurance contract or identification number 853837G Number of Individuals Covered 374 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $27,700 Total amount of fees paid to insurance company USD $3,477 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 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 $262,729 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,535 Insurance broker organization code? 3 Amount paid for insurance broker fees 3477 Additional information about fees paid to insurance broker BONUS Insurance broker name INSURANCE LEADERSHIP NETWORK, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12220855
Policy instance	3
Insurance contract or identification number 12220855 Number of Individuals Covered 259 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $1,988 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 $58,362 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,988 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	2
Insurance contract or identification number 30339 Number of Individuals Covered 22 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 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 $169,476 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	1
Insurance contract or identification number 10001229 Number of Individuals Covered 236 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $28,820 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 $1,050,308 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $28,820 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	1
Insurance contract or identification number 10001229 Number of Individuals Covered 216 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $29,991 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 $926,058 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $29,991 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	2
Insurance contract or identification number 30339 Number of Individuals Covered 35 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 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 $123,369 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: 53031 )
Policy contract number	12220855
Policy instance	3
Insurance contract or identification number 12220855 Number of Individuals Covered 280 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $1,982 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 $57,934 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,982 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	853837G
Policy instance	4
Insurance contract or identification number 853837G Number of Individuals Covered 405 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $27,564 Total amount of fees paid to insurance company USD $3,408 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 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 $261,698 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $27,564 Amount paid for insurance broker fees 3408 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	151928
Policy instance	5
Insurance contract or identification number 151928 Number of Individuals Covered 398 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $90,617 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,277,083 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $90,617 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0114732
Policy instance	6
Insurance contract or identification number 0114732 Number of Individuals Covered 833 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $17,024 Total amount of fees paid to insurance company USD $5,127 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 $317,339 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,024 Amount paid for insurance broker fees 5127 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229264
Policy instance	7
Insurance contract or identification number 229264 Number of Individuals Covered 82 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $16,296 Total amount of fees paid to insurance company USD $45 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 $327,045 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,296 Amount paid for insurance broker fees 45 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090417
Policy instance	8
Insurance contract or identification number 6090417 Number of Individuals Covered 73 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $1,624 Total amount of fees paid to insurance company USD $470 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 LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,667 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,624 Insurance broker organization code? 3 Amount paid for insurance broker fees 470 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker name WELLS FARGO INSURANCE SERVICES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	229264
Policy instance	7
Insurance contract or identification number 229264 Number of Individuals Covered 90 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $16,656 Total amount of fees paid to insurance company USD $38 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 $302,340 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,656 Amount paid for insurance broker fees 38 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	1
Insurance contract or identification number 10001229 Number of Individuals Covered 213 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $37,291 Total amount of fees paid to insurance company USD $720 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit 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 $882,022 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $37,291 Amount paid for insurance broker fees 720 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	2
Insurance contract or identification number 30339 Number of Individuals Covered 20 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 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 $90,773 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: 53031 )
Policy contract number	12220855
Policy instance	3
Insurance contract or identification number 12220855 Number of Individuals Covered 260 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $1,974 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 $55,469 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,974 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	853837G
Policy instance	4
Insurance contract or identification number 853837G Number of Individuals Covered 414 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $25,844 Total amount of fees paid to insurance company USD $548 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 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 $246,221 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,844 Insurance broker organization code? 3 Amount paid for insurance broker fees 548 Additional information about fees paid to insurance broker BONUS Insurance broker name WELLS FARGO INSURANCE SERVICES
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	151928
Policy instance	5
Insurance contract or identification number 151928 Number of Individuals Covered 370 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $80,112 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,033,110 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $80,112 Amount paid for insurance broker fees 2131 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0114732
Policy instance	6
Insurance contract or identification number 0114732 Number of Individuals Covered 796 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $13,420 Total amount of fees paid to insurance company USD $4,772 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 $295,338 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,420 Amount paid for insurance broker fees 4772 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	8
Insurance contract or identification number 30339 Number of Individuals Covered 12 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 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 $12,468 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	619124
Policy instance	8
Insurance contract or identification number 619124 Number of Individuals Covered 194 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $3,587 Total amount of fees paid to insurance company USD $585 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	151928
Policy instance	1
Insurance contract or identification number 151928 Number of Individuals Covered 346 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $72,424 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 $1,766,919 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	853837G
Policy instance	7
Insurance contract or identification number 853837G Number of Individuals Covered 407 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $24,274 Total amount of fees paid to insurance company USD $7,302 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 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 $242,736 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: 53031 )
Policy contract number	12220855
Policy instance	6
Insurance contract or identification number 12220855 Number of Individuals Covered 252 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $1,892 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 $51,128 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0114732
Policy instance	5
Insurance contract or identification number 0114732 Number of Individuals Covered 762 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $14,332 Total amount of fees paid to insurance company USD $5,748 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 $286,155 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	4
Insurance contract or identification number 30339 Number of Individuals Covered 27 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 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 $170,610 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	229264
Policy instance	3
Insurance contract or identification number 229264 Number of Individuals Covered 77 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $11,516 Total amount of fees paid to insurance company USD $97 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 $244,255 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	2
Insurance contract or identification number 10001229 Number of Individuals Covered 220 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $29,896 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 $841,402 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	151928
Policy instance	1
Insurance contract or identification number 151928 Number of Individuals Covered 167 Insurance policy start date 2009-08-01 Insurance policy end date 2010-07-31 Total amount of commissions paid to insurance broker USD $85,332 Total amount of fees paid to insurance company USD $4,986 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 $1,706,643 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $85,332 Amount paid for insurance broker fees 4986 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 )
Policy contract number	10001229
Policy instance	2
Insurance contract or identification number 10001229 Number of Individuals Covered 218 Insurance policy start date 2009-08-01 Insurance policy end date 2010-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $770,237 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number	30339
Policy instance	4
Insurance contract or identification number 30339 Number of Individuals Covered 28 Insurance policy start date 2009-05-01 Insurance policy end date 2010-04-30 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 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 $196,967 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	229264
Policy instance	3
Insurance contract or identification number 229264 Number of Individuals Covered 78 Insurance policy start date 2009-08-01 Insurance policy end date 2010-07-31 Total amount of commissions paid to insurance broker USD $9,262 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 $195,127 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,262 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0114732
Policy instance	5
Insurance contract or identification number 0114732 Number of Individuals Covered 803 Insurance policy start date 2009-08-01 Insurance policy end date 2010-07-31 Total amount of commissions paid to insurance broker USD $15,116 Total amount of fees paid to insurance company USD $5,580 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 $277,225 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,385 Amount paid for insurance broker fees 10 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURNACE SERVICES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12220855
Policy instance	6
Insurance contract or identification number 12220855 Number of Individuals Covered 275 Insurance policy start date 2009-08-01 Insurance policy end date 2010-07-31 Total amount of commissions paid to insurance broker USD $1,871 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 $50,123 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,871 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	853837G
Policy instance	7
Insurance contract or identification number 853837G Number of Individuals Covered 431 Insurance policy start date 2009-08-01 Insurance policy end date 2010-07-31 Total amount of commissions paid to insurance broker USD $24,102 Total amount of fees paid to insurance company USD $5,508 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 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 $241,020 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,102 Amount paid for insurance broker fees 34 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	619124
Policy instance	8
Insurance contract or identification number 619124 Number of Individuals Covered 197 Insurance policy start date 2009-08-01 Insurance policy end date 2010-07-31 Total amount of commissions paid to insurance broker USD $3,455 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,251 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES