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PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan NamePACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN
Plan identification number 501

PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

PACIFIC HOTEL MANAGEMENT, LLC has sponsored the creation of one or more 401k plans.

Company Name:PACIFIC HOTEL MANAGEMENT, LLC
Employer identification number (EIN):942749016
NAIC Classification:531210
NAIC Description:Offices of Real Estate Agents and Brokers

Additional information about PACIFIC HOTEL MANAGEMENT, LLC

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: 199636210023

More information about PACIFIC HOTEL MANAGEMENT, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01CLEMENT CHEN, III CLEMENT CHEN2019-07-16
5012017-01-01CLEMENT CHEN, III CLEMENT CHEN2018-05-01
5012016-01-01CLEMENT CHEN, III CLEMENT CHEN, III2017-06-23
5012015-01-01CLEMENT CHEN, III CLEMENT CHEN, III2016-07-11
5012014-01-01CLEMENT CHEN, III CLEMENT CHEN, III2015-07-06
5012013-01-01CLEMENT CHEN, III
5012012-01-01CLEMENT CHEN, III CLEMENT CHEN, III2013-06-19
5012011-01-01CLEMENT CHEN, III
5012010-01-01CLEMENT CHEN, III
5012009-01-01CLEMENT CHEN, III

Plan Statistics for PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01356
Total number of active participants reported on line 7a of the Form 55002022-01-01459
Total of all active and inactive participants2022-01-01459
2021: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01210
Total number of active participants reported on line 7a of the Form 55002021-01-01356
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01356
2020: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01710
Total number of active participants reported on line 7a of the Form 55002020-01-01210
Total of all active and inactive participants2020-01-01210
2019: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01749
Total number of active participants reported on line 7a of the Form 55002019-01-01710
Total of all active and inactive participants2019-01-01710
2018: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01671
Total number of active participants reported on line 7a of the Form 55002018-01-01749
Total of all active and inactive participants2018-01-01749
2017: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01550
Total number of active participants reported on line 7a of the Form 55002017-01-01617
Total of all active and inactive participants2017-01-01617
2016: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01544
Total number of active participants reported on line 7a of the Form 55002016-01-01550
Total of all active and inactive participants2016-01-01550
2015: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01557
Total number of active participants reported on line 7a of the Form 55002015-01-01541
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-013
Total of all active and inactive participants2015-01-01544
2014: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01660
Total number of active participants reported on line 7a of the Form 55002014-01-01544
Number of retired or separated participants receiving benefits2014-01-019
Number of other retired or separated participants entitled to future benefits2014-01-014
Total of all active and inactive participants2014-01-01557
2013: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01677
Total number of active participants reported on line 7a of the Form 55002013-01-01657
Number of retired or separated participants receiving benefits2013-01-012
Number of other retired or separated participants entitled to future benefits2013-01-011
Total of all active and inactive participants2013-01-01660
2012: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01720
Total number of active participants reported on line 7a of the Form 55002012-01-01657
Number of retired or separated participants receiving benefits2012-01-013
Number of other retired or separated participants entitled to future benefits2012-01-0117
Total of all active and inactive participants2012-01-01677
2011: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01657
Total number of active participants reported on line 7a of the Form 55002011-01-01709
Number of retired or separated participants receiving benefits2011-01-012
Number of other retired or separated participants entitled to future benefits2011-01-0113
Total of all active and inactive participants2011-01-01724
2010: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01623
Total number of active participants reported on line 7a of the Form 55002010-01-01637
Number of retired or separated participants receiving benefits2010-01-014
Number of other retired or separated participants entitled to future benefits2010-01-0116
Total of all active and inactive participants2010-01-01657
2009: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01443
Total number of active participants reported on line 7a of the Form 55002009-01-01620
Number of retired or separated participants receiving benefits2009-01-013
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-01623

Form 5500 Responses for PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN

2022: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: PACIFIC HOTEL MANAGEMENT EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE 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 CarrierUSD $5,998
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 number7613
Policy instance 5
Insurance contract or identification number7613
Number of Individuals Covered129
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $18,236
Total amount of fees paid to insurance companyUSD $28
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,015,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,236
Amount paid for insurance broker fees28
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number76968, N6165
Policy instance 4
Insurance contract or identification number76968, N6165
Number of Individuals Covered78
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,290,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00568130
Policy instance 3
Insurance contract or identification number00568130
Number of Individuals Covered422
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $7,647
Total amount of fees paid to insurance companyUSD $5,224
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $250,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,647
Amount paid for insurance broker fees5224
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9939562
Policy instance 2
Insurance contract or identification number9939562
Number of Individuals Covered264
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PLAN
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00568130
Policy instance 3
Insurance contract or identification number00568130
Number of Individuals Covered356
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $4,824
Total amount of fees paid to insurance companyUSD $11,851
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, VOL. AD&D, VOL. LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $132,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,824
Amount paid for insurance broker fees11851
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number76968, N6165
Policy instance 4
Insurance contract or identification number76968, N6165
Number of Individuals Covered65
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $906,713
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 number7613
Policy instance 5
Insurance contract or identification number7613
Number of Individuals Covered131
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $17,609
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $852,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,609
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9939562
Policy instance 2
Insurance contract or identification number9939562
Number of Individuals Covered206
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PLAN
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,998
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 number7613
Policy instance 5
Insurance contract or identification number7613
Number of Individuals Covered108
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $27,338
Total amount of fees paid to insurance companyUSD $7
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,331,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,338
Amount paid for insurance broker fees7
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number76968, N6165
Policy instance 4
Insurance contract or identification number76968, N6165
Number of Individuals Covered59
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,645,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00568130
Policy instance 3
Insurance contract or identification number00568130
Number of Individuals Covered210
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $8,561
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $254,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,561
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9939562
Policy instance 2
Insurance contract or identification number9939562
Number of Individuals Covered153
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,582
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 number0146708
Policy instance 5
Insurance contract or identification number0146708
Number of Individuals Covered710
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $41
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $313,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees41
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number7613
Policy instance 4
Insurance contract or identification number7613
Number of Individuals Covered236
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $33,677
Total amount of fees paid to insurance companyUSD $6
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,650,440
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,677
Amount paid for insurance broker fees6
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9939562
Policy instance 2
Insurance contract or identification number9939562
Number of Individuals Covered389
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PLAN
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number0146708
Policy instance 6
Insurance contract or identification number0146708
Number of Individuals Covered296
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $38,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number76968, N6165
Policy instance 3
Insurance contract or identification number76968, N6165
Number of Individuals Covered159
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,095,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number76968, N6165
Policy instance 3
Insurance contract or identification number76968, N6165
Number of Individuals Covered168
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,128,901
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 number7613
Policy instance 4
Insurance contract or identification number7613
Number of Individuals Covered234
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $29,313
Total amount of fees paid to insurance companyUSD $5
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,561,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,313
Amount paid for insurance broker fees5
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0146708
Policy instance 5
Insurance contract or identification number0146708
Number of Individuals Covered749
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $45
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $287,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees45
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number0146708
Policy instance 6
Insurance contract or identification number0146708
Number of Individuals Covered278
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $35,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9939562
Policy instance 2
Insurance contract or identification number9939562
Number of Individuals Covered334
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $33,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PLAN
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number0146708
Policy instance 6
Insurance contract or identification number0146708
Number of Individuals Covered208
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $38,739
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 number7613
Policy instance 4
Insurance contract or identification number7613
Number of Individuals Covered243
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $27,422
Total amount of fees paid to insurance companyUSD $48
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,352,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,422
Amount paid for insurance broker fees48
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INS SVCS OF CA
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0146708
Policy instance 5
Insurance contract or identification number0146708
Number of Individuals Covered785
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $275,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees31
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INSURANCE SVCS OF CA
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PLAN
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9939562
Policy instance 2
Insurance contract or identification number9939562
Number of Individuals Covered365
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number76968, N6165
Policy instance 3
Insurance contract or identification number76968, N6165
Number of Individuals Covered184
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,078,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number76968, N6165
Policy instance 3
Insurance contract or identification number76968, N6165
Number of Individuals Covered165
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,665,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number0146708
Policy instance 6
Insurance contract or identification number0146708
Number of Individuals Covered358
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $44,409
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 number0146708
Policy instance 5
Insurance contract or identification number0146708
Number of Individuals Covered645
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $15
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $234,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees15
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INSURANCE SVCS OF CA
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number7613
Policy instance 4
Insurance contract or identification number7613
Number of Individuals Covered235
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $26,699
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,322,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,699
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INS SVCS OF CA
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9939562
Policy instance 2
Insurance contract or identification number9939562
Number of Individuals Covered331
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PLAN
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,998
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 number0146708
Policy instance 5
Insurance contract or identification number0146708
Number of Individuals Covered656
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $237,437
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 number7613
Policy instance 1
Insurance contract or identification number7613
Number of Individuals Covered233
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $25,306
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,287,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,306
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INS SVCS OF CA
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number106461
Policy instance 2
Insurance contract or identification number106461
Number of Individuals Covered1
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $646
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $646
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INS SVCS OF CA
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 3
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PLAN
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number0146708
Policy instance 4
Insurance contract or identification number0146708
Number of Individuals Covered360
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $42,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30005564
Policy instance 6
Insurance contract or identification number30005564
Number of Individuals Covered215
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $1,352
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,352
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INSURANCE SERVICES
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number76968, N6165
Policy instance 7
Insurance contract or identification number76968, N6165
Number of Individuals Covered176
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,749,956
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 number7613
Policy instance 1
Insurance contract or identification number7613
Number of Individuals Covered229
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $22,830
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,138,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,830
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INS SVCS OF CA
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number76968, N6165
Policy instance 7
Insurance contract or identification number76968, N6165
Number of Individuals Covered231
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,789,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30005564
Policy instance 6
Insurance contract or identification number30005564
Number of Individuals Covered253
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $1,463
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $32,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,463
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INSURANCE SERVICES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0146708
Policy instance 5
Insurance contract or identification number0146708
Number of Individuals Covered805
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD & D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $278,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number0146708
Policy instance 4
Insurance contract or identification number0146708
Number of Individuals Covered433
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $46,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 3
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE 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 CarrierUSD $5,874
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 number106461
Policy instance 2
Insurance contract or identification number106461
Number of Individuals Covered29
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $3,220
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $171,052
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,220
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INS SVCS OF CA
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number106461
Policy instance 2
Insurance contract or identification number106461
Number of Individuals Covered32
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $3,420
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $176,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,420
Insurance broker organization code?3
Insurance broker nameSITZMANN MORRIS & LAVIS INSURANCE
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30005564
Policy instance 7
Insurance contract or identification number30005564
Number of Individuals Covered240
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,438
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $31,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,438
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN INSURANCE SERVICES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0146708
Policy instance 6
Insurance contract or identification number0146708
Number of Individuals Covered827
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $253,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number0146708
Policy instance 5
Insurance contract or identification number0146708
Number of Individuals Covered377
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $41,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number711557
Policy instance 4
Insurance contract or identification number711557
Number of Individuals Covered293
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,715,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 3
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE 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 CarrierUSD $5,874
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 number7613
Policy instance 1
Insurance contract or identification number7613
Number of Individuals Covered269
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $23,984
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,241,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15
Insurance broker organization code?3
Insurance broker nameSITZMANN MORRIS & LAVIS INS AGENCY
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0146708
Policy instance 4
Insurance contract or identification number0146708
Number of Individuals Covered853
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $214,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30005564
Policy instance 8
Insurance contract or identification number30005564
Number of Individuals Covered236
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $1,394
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $29,595
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 number106461
Policy instance 2
Insurance contract or identification number106461
Number of Individuals Covered28
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $3,189
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $149,757
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 number0711557
Policy instance 7
Insurance contract or identification number0711557
Number of Individuals Covered162
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $688,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number525802 - 525810
Policy instance 6
Insurance contract or identification number525802 - 525810
Number of Individuals Covered153
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $998,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number0146708
Policy instance 5
Insurance contract or identification number0146708
Number of Individuals Covered441
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $48,022
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 number7613
Policy instance 3
Insurance contract or identification number7613
Number of Individuals Covered199
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $25,299
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,148,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE 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 CarrierUSD $5,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number2119
Policy instance 3
Insurance contract or identification number2119
Number of Individuals Covered251
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number990
Policy instance 2
Insurance contract or identification number990
Number of Individuals Covered270
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $2,713
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $55,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,713
Insurance broker organization code?3
Insurance broker nameSITZMANN, MORRIS & LAVIS
UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )
Policy contract number302468
Policy instance 8
Insurance contract or identification number302468
Number of Individuals Covered637
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $1,903
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD & D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $44,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,903
Insurance broker organization code?3
Insurance broker nameSITZMANN MORRIS & LAVIS, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0711557
Policy instance 7
Insurance contract or identification number0711557
Number of Individuals Covered154
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $707,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number525802 - 525810
Policy instance 6
Insurance contract or identification number525802 - 525810
Number of Individuals Covered166
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,055,336
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 number7613
Policy instance 5
Insurance contract or identification number7613
Number of Individuals Covered200
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $22,128
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,150,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,128
Insurance broker organization code?3
Insurance broker nameSITZMANN MORRIS & LAVIS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number106461
Policy instance 4
Insurance contract or identification number106461
Number of Individuals Covered29
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $2,984
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $153,976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,984
Insurance broker organization code?3
Insurance broker nameSITZMANN MORRIS & LAVIS, INC.
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered259
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE 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 CarrierUSD $5,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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