HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN
Plan identification number	501

HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

HARBOR VIEW HOLDINGS, INC. has sponsored the creation of one or more 401k plans.

Company Name:	HARBOR VIEW HOLDINGS, INC.
Employer identification number (EIN):	942945061
NAIC Classification:	721110
NAIC Description:	Hotels (except Casino Hotels) and Motels

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-08-01	MEE MEE KIONG	2024-02-06
501	2021-08-01	MEE MEE KIONG	2023-02-14
501	2020-08-01	MEE MEE KIONG	2022-02-03
501	2019-08-01	J. L. HELVEY	2021-01-28
501	2018-08-01	J. L. HELVEY	2020-02-11
501	2017-08-01
501	2016-08-01
501	2015-08-01	TRACEY HOLLOWAY
501	2014-08-01	JAMES E M EVANS
501	2013-08-01	JAMES EVANS
501	2012-08-01	JAMES EVANS

Plan Statistics for HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN

Measure	Date	Value
2022: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-08-01	555
Total number of active participants reported on line 7a of the Form 5500	2022-08-01	722
Number of retired or separated participants receiving benefits	2022-08-01	0
Number of other retired or separated participants entitled to future benefits	2022-08-01	0
Total of all active and inactive participants	2022-08-01	722
Number of employers contributing to the scheme	2022-08-01	0
2021: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-08-01	422
Total number of active participants reported on line 7a of the Form 5500	2021-08-01	555
Number of retired or separated participants receiving benefits	2021-08-01	1
Number of other retired or separated participants entitled to future benefits	2021-08-01	0
Total of all active and inactive participants	2021-08-01	556
Number of employers contributing to the scheme	2021-08-01	0
2020: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-08-01	295
Total number of active participants reported on line 7a of the Form 5500	2020-08-01	422
Number of retired or separated participants receiving benefits	2020-08-01	0
Number of other retired or separated participants entitled to future benefits	2020-08-01	0
Total of all active and inactive participants	2020-08-01	422
Number of employers contributing to the scheme	2020-08-01	0
2019: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-08-01	1,900
Total number of active participants reported on line 7a of the Form 5500	2019-08-01	283
Number of retired or separated participants receiving benefits	2019-08-01	12
Number of other retired or separated participants entitled to future benefits	2019-08-01	0
Total of all active and inactive participants	2019-08-01	295
Number of employers contributing to the scheme	2019-08-01	0
2018: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-08-01	1,900
Total number of active participants reported on line 7a of the Form 5500	2018-08-01	1,900
Number of retired or separated participants receiving benefits	2018-08-01	0
Number of other retired or separated participants entitled to future benefits	2018-08-01	0
Total of all active and inactive participants	2018-08-01	1,900
Number of employers contributing to the scheme	2018-08-01	0
2017: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-08-01	1,315
Total number of active participants reported on line 7a of the Form 5500	2017-08-01	1,219
Number of retired or separated participants receiving benefits	2017-08-01	6
Number of other retired or separated participants entitled to future benefits	2017-08-01	45
Total of all active and inactive participants	2017-08-01	1,270
Number of employers contributing to the scheme	2017-08-01	0
2016: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-08-01	1,314
Total number of active participants reported on line 7a of the Form 5500	2016-08-01	1,315
Number of retired or separated participants receiving benefits	2016-08-01	0
Number of other retired or separated participants entitled to future benefits	2016-08-01	0
Total of all active and inactive participants	2016-08-01	1,315
2015: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-08-01	1,209
Total number of active participants reported on line 7a of the Form 5500	2015-08-01	1,314
Number of retired or separated participants receiving benefits	2015-08-01	0
Number of other retired or separated participants entitled to future benefits	2015-08-01	0
Total of all active and inactive participants	2015-08-01	1,314
2014: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-08-01	1,614
Total number of active participants reported on line 7a of the Form 5500	2014-08-01	1,209
Number of retired or separated participants receiving benefits	2014-08-01	0
Number of other retired or separated participants entitled to future benefits	2014-08-01	0
Total of all active and inactive participants	2014-08-01	1,209
2013: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-08-01	1,617
Total number of active participants reported on line 7a of the Form 5500	2013-08-01	1,614
Number of retired or separated participants receiving benefits	2013-08-01	0
Number of other retired or separated participants entitled to future benefits	2013-08-01	0
Total of all active and inactive participants	2013-08-01	1,614
2012: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-08-01	1,618
Total number of active participants reported on line 7a of the Form 5500	2012-08-01	1,614
Number of retired or separated participants receiving benefits	2012-08-01	3
Number of other retired or separated participants entitled to future benefits	2012-08-01	0
Total of all active and inactive participants	2012-08-01	1,617

Form 5500 Responses for HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN

2022: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-08-01	Type of plan entity	Single employer plan
2022-08-01	Plan funding arrangement – Insurance	Yes
2022-08-01	Plan benefit arrangement – Insurance	Yes
2021: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-08-01	Type of plan entity	Single employer plan
2021-08-01	Plan funding arrangement – Insurance	Yes
2021-08-01	Plan benefit arrangement – Insurance	Yes
2020: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-08-01	Type of plan entity	Single employer plan
2020-08-01	Plan funding arrangement – Insurance	Yes
2020-08-01	Plan benefit arrangement – Insurance	Yes
2019: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-08-01	Type of plan entity	Single employer plan
2019-08-01	Plan funding arrangement – Insurance	Yes
2019-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-08-01	Plan benefit arrangement – Insurance	Yes
2019-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-08-01	Type of plan entity	Single employer plan
2018-08-01	Plan funding arrangement – Insurance	Yes
2018-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-08-01	Plan benefit arrangement – Insurance	Yes
2018-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-08-01	Type of plan entity	Single employer plan
2017-08-01	Plan funding arrangement – Insurance	Yes
2017-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-08-01	Plan benefit arrangement – Insurance	Yes
2017-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-08-01	Type of plan entity	Single employer plan
2016-08-01	Submission has been amended	No
2016-08-01	This submission is the final filing	No
2016-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-08-01	Plan is a collectively bargained plan	No
2016-08-01	Plan funding arrangement – Insurance	Yes
2016-08-01	Plan benefit arrangement – Insurance	Yes
2015: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-08-01	Type of plan entity	Single employer plan
2015-08-01	Submission has been amended	No
2015-08-01	This submission is the final filing	No
2015-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-08-01	Plan is a collectively bargained plan	No
2015-08-01	Plan funding arrangement – Insurance	Yes
2015-08-01	Plan benefit arrangement – Insurance	Yes
2014: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-08-01	Type of plan entity	Single employer plan
2014-08-01	Submission has been amended	No
2014-08-01	This submission is the final filing	No
2014-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-08-01	Plan is a collectively bargained plan	No
2014-08-01	Plan funding arrangement – Insurance	Yes
2014-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-08-01	Plan benefit arrangement – Insurance	Yes
2014-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-08-01	Type of plan entity	Single employer plan
2013-08-01	Submission has been amended	No
2013-08-01	This submission is the final filing	No
2013-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-08-01	Plan is a collectively bargained plan	No
2013-08-01	Plan funding arrangement – Insurance	Yes
2013-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-08-01	Plan benefit arrangement – Insurance	Yes
2013-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: HARBOR VIEW HOLDINGS, INC. HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-08-01	Type of plan entity	Single employer plan
2012-08-01	Submission has been amended	No
2012-08-01	This submission is the final filing	No
2012-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-08-01	Plan is a collectively bargained plan	No
2012-08-01	Plan funding arrangement – Insurance	Yes
2012-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-08-01	Plan benefit arrangement – Insurance	Yes
2012-08-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	87806/87807
Policy instance	4
Insurance contract or identification number 87806/87807 Number of Individuals Covered 256 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,640,973 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	677120G
Policy instance	10
Insurance contract or identification number 677120G Number of Individuals Covered 722 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $34,355 Total amount of fees paid to insurance company USD $4,925 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $344,780 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,355 Amount paid for insurance broker fees 4925 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12263548
Policy instance	1
Insurance contract or identification number 12263548 Number of Individuals Covered 661 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $1,528 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $55,691 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,528 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	113807
Policy instance	2
Insurance contract or identification number 113807 Number of Individuals Covered 30 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $374 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $9,594 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 374 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	808633
Policy instance	3
Insurance contract or identification number 808633 Number of Individuals Covered 1101 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $7,469 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $386,406 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,469 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	2583
Policy instance	5
Insurance contract or identification number 2583 Number of Individuals Covered 319 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $94,657 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	34498
Policy instance	6
Insurance contract or identification number 34498 Number of Individuals Covered 65 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $323,302 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277253
Policy instance	7
Insurance contract or identification number 277253 Number of Individuals Covered 640 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $95,652 Total amount of fees paid to insurance company USD $2,941 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,977,767 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $95,652 Amount paid for insurance broker fees 2941 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	340
Policy instance	8
Insurance contract or identification number 340 Number of Individuals Covered 51 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $9,659 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $137,990 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $9,659 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	19132
Policy instance	9
Insurance contract or identification number 19132 Number of Individuals Covered 297 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $37,635 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $3,713,475 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $37,635 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	340
Policy instance	8
Insurance contract or identification number 340 Number of Individuals Covered 40 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $6,412 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $91,603 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $6,412 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12263548
Policy instance	1
Insurance contract or identification number 12263548 Number of Individuals Covered 487 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $2,345 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $43,724 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,345 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	233373
Policy instance	2
Insurance contract or identification number 233373 Number of Individuals Covered 29 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $257 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,967 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 257 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	808633
Policy instance	3
Insurance contract or identification number 808633 Number of Individuals Covered 890 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $6,969 Total amount of fees paid to insurance company USD $46 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $346,258 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,969 Amount paid for insurance broker fees 46 Additional information about fees paid to insurance broker INDIRECT COMPENSATION Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	87806/87807
Policy instance	4
Insurance contract or identification number 87806/87807 Number of Individuals Covered 238 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,653,924 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	2583
Policy instance	5
Insurance contract or identification number 2583 Number of Individuals Covered 138 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $86,807 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	34498
Policy instance	6
Insurance contract or identification number 34498 Number of Individuals Covered 52 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $269,700 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277253
Policy instance	7
Insurance contract or identification number 277253 Number of Individuals Covered 533 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $69,057 Total amount of fees paid to insurance company USD $5,318 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,446,623 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $69,057 Amount paid for insurance broker fees 5318 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	677120G
Policy instance	9
Insurance contract or identification number 677120G Number of Individuals Covered 555 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $29,761 Total amount of fees paid to insurance company USD $3,163 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $290,393 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,761 Amount paid for insurance broker fees 3163 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	19132
Policy instance	10
Insurance contract or identification number 19132 Number of Individuals Covered 335 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $23,323 Total amount of fees paid to insurance company USD $1,019 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $2,325,455 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,323 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker BONUS
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	233373
Policy instance	2
Insurance contract or identification number 233373 Number of Individuals Covered 26 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,291 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	340
Policy instance	3
Insurance contract or identification number 340 Number of Individuals Covered 16 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $2,715 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $38,780 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $2,715 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	808633
Policy instance	4
Insurance contract or identification number 808633 Number of Individuals Covered 728 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $5,351 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $269,499 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,351 Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	87806/87807
Policy instance	5
Insurance contract or identification number 87806/87807 Number of Individuals Covered 258 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $902,981 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12263548
Policy instance	1
Insurance contract or identification number 12263548 Number of Individuals Covered 749 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $777 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $66,480 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $777 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	34498
Policy instance	7
Insurance contract or identification number 34498 Number of Individuals Covered 41 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $105,802 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277253
Policy instance	8
Insurance contract or identification number 277253 Number of Individuals Covered 437 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $49,396 Total amount of fees paid to insurance company USD $11,120 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,412,991 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $49,396 Amount paid for insurance broker fees 11120 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	19132
Policy instance	9
Insurance contract or identification number 19132 Number of Individuals Covered 233 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $17,995 Total amount of fees paid to insurance company USD $4,535 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $1,571,748 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,995 Amount paid for insurance broker fees 13 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	677120G
Policy instance	10
Insurance contract or identification number 677120G Number of Individuals Covered 422 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $18,099 Total amount of fees paid to insurance company USD $4,064 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $172,073 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,099 Amount paid for insurance broker fees 4064 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	2583
Policy instance	6
Insurance contract or identification number 2583 Number of Individuals Covered 302 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $50,386 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	87806/87807
Policy instance	4
Insurance contract or identification number 87806/87807 Number of Individuals Covered 18 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,523,756 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	340
Policy instance	3
Insurance contract or identification number 340 Number of Individuals Covered 0 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $12,422 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $177,452 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,422 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	233373
Policy instance	2
Insurance contract or identification number 233373 Number of Individuals Covered 29 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $16,379 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12263548
Policy instance	1
Insurance contract or identification number 12263548 Number of Individuals Covered 309 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $76,493 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	2583
Policy instance	5
Insurance contract or identification number 2583 Number of Individuals Covered 30 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $163,288 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	34498
Policy instance	6
Insurance contract or identification number 34498 Number of Individuals Covered 4 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $386,201 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277253
Policy instance	7
Insurance contract or identification number 277253 Number of Individuals Covered 360 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $129,790 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,757,967 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $129,790 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0808633-00000
Policy instance	8
Insurance contract or identification number 0808633-00000 Number of Individuals Covered 713 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $12,973 Total amount of fees paid to insurance company USD $98 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $598,289 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,973 Amount paid for insurance broker fees 98 Additional information about fees paid to insurance broker INDIRECT COMPENSATION Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	19132
Policy instance	9
Insurance contract or identification number 19132 Number of Individuals Covered 213 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $30,305 Total amount of fees paid to insurance company USD $6 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $3,688,781 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,305 Amount paid for insurance broker fees 6 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	677120G
Policy instance	10
Insurance contract or identification number 677120G Number of Individuals Covered 283 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $40,844 Total amount of fees paid to insurance company USD $7,112 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $396,920 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $40,844 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker BONUS, BONUS
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	87806/87807
Policy instance	4
Insurance contract or identification number 87806/87807 Number of Individuals Covered 484 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,649,153 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	340
Policy instance	3
Insurance contract or identification number 340 Number of Individuals Covered 81 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $14,216 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $203,088 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $14,216 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	233373
Policy instance	2
Insurance contract or identification number 233373 Number of Individuals Covered 59 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $19,272 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12263548
Policy instance	1
Insurance contract or identification number 12263548 Number of Individuals Covered 949 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $2,227 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $84,581 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $2,227 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	2583
Policy instance	5
Insurance contract or identification number 2583 Number of Individuals Covered 555 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $176,239 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	34498
Policy instance	6
Insurance contract or identification number 34498 Number of Individuals Covered 72 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $387,490 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277253
Policy instance	7
Insurance contract or identification number 277253 Number of Individuals Covered 1039 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $126,730 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,374,686 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $126,730 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0808633-00000
Policy instance	8
Insurance contract or identification number 0808633-00000 Number of Individuals Covered 1780 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $13,793 Total amount of fees paid to insurance company USD $88 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $704,273 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,793 Amount paid for insurance broker fees 88 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	19132
Policy instance	9
Insurance contract or identification number 19132 Number of Individuals Covered 605 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $43,206 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $3,946,474 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $43,206 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	677120G
Policy instance	10
Insurance contract or identification number 677120G Number of Individuals Covered 1175 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $42,071 Total amount of fees paid to insurance company USD $2,509 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $404,362 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $42,071 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker BONUS
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	677120G
Policy instance	10
Insurance contract or identification number 677120G Number of Individuals Covered 1267 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $29,557 Total amount of fees paid to insurance company USD $3,033 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $295,497 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,587 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker BONUS Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	19132
Policy instance	9
Insurance contract or identification number 19132 Number of Individuals Covered 587 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $39,307 Total amount of fees paid to insurance company USD $2,567 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $3,603,993 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39,307 Amount paid for insurance broker fees 2567 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION BONUS Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277253
Policy instance	7
Insurance contract or identification number 277253 Number of Individuals Covered 1003 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $118,972 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,980,365 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $118,972 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12263548
Policy instance	1
Insurance contract or identification number 12263548 Number of Individuals Covered 932 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $2,318 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $84,672 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,318 Amount paid for insurance broker fees 0 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	233373
Policy instance	2
Insurance contract or identification number 233373 Number of Individuals Covered 75 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $1,619 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $21,874 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $1,619 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	340
Policy instance	3
Insurance contract or identification number 340 Number of Individuals Covered 84 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $13,323 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $190,331 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $13,323 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	87806/87807
Policy instance	4
Insurance contract or identification number 87806/87807 Number of Individuals Covered 484 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,334,633 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	2583
Policy instance	5
Insurance contract or identification number 2583 Number of Individuals Covered 551 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $180,820 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	34498
Policy instance	6
Insurance contract or identification number 34498 Number of Individuals Covered 71 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $329,432 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	19132/228407
Policy instance	1
Insurance contract or identification number 19132/228407 Number of Individuals Covered 607 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $37,130 Total amount of fees paid to insurance company USD $4,819 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,410,829 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $37,130 Amount paid for insurance broker fees 4819 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	34498
Policy instance	2
Insurance contract or identification number 34498 Number of Individuals Covered 71 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $271,489 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	87807
Policy instance	3
Insurance contract or identification number 87807 Number of Individuals Covered 474 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,919,180 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	340
Policy instance	4
Insurance contract or identification number 340 Number of Individuals Covered 97 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $14,102 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $201,463 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $14,102 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277253
Policy instance	5
Insurance contract or identification number 277253 Number of Individuals Covered 988 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $110,371 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,443,438 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $110,371 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	233373
Policy instance	6
Insurance contract or identification number 233373 Number of Individuals Covered 65 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $1,497 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20,631 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $1,497 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	2583
Policy instance	7
Insurance contract or identification number 2583 Number of Individuals Covered 542 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $171,961 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	808633 ET AL
Policy instance	8
Insurance contract or identification number 808633 ET AL Number of Individuals Covered 1738 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $14,166 Total amount of fees paid to insurance company USD $12,632 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $677,131 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,166 Amount paid for insurance broker fees 12517 Additional information about fees paid to insurance broker 2014/2015 PPP ENGAGEMENT CREDIT Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12263548
Policy instance	9
Insurance contract or identification number 12263548 Number of Individuals Covered 925 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $2,360 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,360 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	677120G
Policy instance	10
Insurance contract or identification number 677120G Number of Individuals Covered 1314 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $15,535 Total amount of fees paid to insurance company USD $2,164 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $153,286 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,535 Insurance broker organization code? 3 Amount paid for insurance broker fees 2164 Additional information about fees paid to insurance broker BONUS Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	87806
Policy instance	4
Insurance contract or identification number 87806 Number of Individuals Covered 446 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,677,138 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	340
Policy instance	3
Insurance contract or identification number 340 Number of Individuals Covered 100 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $12,444 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $177,778 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $12,444 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	808633 ET AL
Policy instance	1
Insurance contract or identification number 808633 ET AL Number of Individuals Covered 1790 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $13,283 Total amount of fees paid to insurance company USD $306 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $672,075 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,283 Insurance broker organization code? 3 Amount paid for insurance broker fees 306 Additional information about fees paid to insurance broker INDIRECT COMPENSATION Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	19132/228407
Policy instance	2
Insurance contract or identification number 19132/228407 Number of Individuals Covered 590 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $34,865 Total amount of fees paid to insurance company USD $590 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,369,035 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,865 Insurance broker organization code? 3 Amount paid for insurance broker fees 590 Additional information about fees paid to insurance broker BONUS Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	2583
Policy instance	5
Insurance contract or identification number 2583 Number of Individuals Covered 513 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $160,602 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	677120G
Policy instance	6
Insurance contract or identification number 677120G Number of Individuals Covered 1209 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $14,659 Total amount of fees paid to insurance company USD $2,888 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $148,625 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,659 Insurance broker organization code? 3 Amount paid for insurance broker fees 2888 Additional information about fees paid to insurance broker BONUS Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12263548
Policy instance	7
Insurance contract or identification number 12263548 Number of Individuals Covered 951 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $2,374 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,374 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277253
Policy instance	11
Insurance contract or identification number 277253 Number of Individuals Covered 1027 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $111,064 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,629,464 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $111,064 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	34498
Policy instance	10
Insurance contract or identification number 34498 Number of Individuals Covered 73 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $276,584 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	20226
Policy instance	9
Insurance contract or identification number 20226 Number of Individuals Covered 34 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $6,330 Total amount of fees paid to insurance company USD $500 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $207,208 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,330 Amount paid for insurance broker fees 500 Additional information about fees paid to insurance broker ANNUAL BOB Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	233373
Policy instance	8
Insurance contract or identification number 233373 Number of Individuals Covered 69 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $1,620 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,036 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $1,620 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	808633 ET AL
Policy instance	1
Insurance contract or identification number 808633 ET AL Number of Individuals Covered 1784 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $13,115 Total amount of fees paid to insurance company USD $636 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $652,683 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,624 Insurance broker organization code? 3 Amount paid for insurance broker fees 636 Additional information about fees paid to insurance broker INDIRECT COMPENSATION Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	19132/228407
Policy instance	2
Insurance contract or identification number 19132/228407 Number of Individuals Covered 597 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $46,869 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,350,564 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $46,869 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	340
Policy instance	3
Insurance contract or identification number 340 Number of Individuals Covered 69 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $8,761 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $125,164 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $8,761 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	87806
Policy instance	4
Insurance contract or identification number 87806 Number of Individuals Covered 440 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,479,200 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	2583
Policy instance	5
Insurance contract or identification number 2583 Number of Individuals Covered 515 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $166,261 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	677120G
Policy instance	6
Insurance contract or identification number 677120G Number of Individuals Covered 1614 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $12,911 Total amount of fees paid to insurance company USD $2,707 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $126,735 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,911 Amount paid for insurance broker fees 2707 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12263548
Policy instance	7
Insurance contract or identification number 12263548 Number of Individuals Covered 927 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $2,279 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,279 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	233373
Policy instance	8
Insurance contract or identification number 233373 Number of Individuals Covered 69 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $1,466 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $19,776 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $1,466 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	20226
Policy instance	9
Insurance contract or identification number 20226 Number of Individuals Covered 38 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $6,028 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $193,636 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,028 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	34498
Policy instance	10
Insurance contract or identification number 34498 Number of Individuals Covered 71 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $247,239 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277253
Policy instance	11
Insurance contract or identification number 277253 Number of Individuals Covered 955 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $102,510 Total amount of fees paid to insurance company USD $100 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,990,074 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $102,510 Amount paid for insurance broker fees 100 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC
HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	2583
Policy instance	5
Insurance contract or identification number 2583 Number of Individuals Covered 473 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $154,073 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	87806
Policy instance	4
Insurance contract or identification number 87806 Number of Individuals Covered 404 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,434,569 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	340
Policy instance	3
Insurance contract or identification number 340 Number of Individuals Covered 58 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $7,386 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $105,515 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $7,386 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	19132/228407
Policy instance	2
Insurance contract or identification number 19132/228407 Number of Individuals Covered 591 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $41,816 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,875,820 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $41,816 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	677120G
Policy instance	6
Insurance contract or identification number 677120G Number of Individuals Covered 1614 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $12,421 Total amount of fees paid to insurance company USD $2,566 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $124,460 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,421 Insurance broker organization code? 3 Amount paid for insurance broker fees 2566 Additional information about fees paid to insurance broker BONUS Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	808633 ET AL
Policy instance	1
Insurance contract or identification number 808633 ET AL Number of Individuals Covered 1680 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $12,004 Total amount of fees paid to insurance company USD $148 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $606,976 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,004 Insurance broker organization code? 3 Amount paid for insurance broker fees 148 Additional information about fees paid to insurance broker INDIRECT COMPENSATION Insurance broker name GALLAGHER BENEFIT SERVICES
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	233373
Policy instance	8
Insurance contract or identification number 233373 Number of Individuals Covered 68 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $1,370 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $18,268 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,370 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	20226
Policy instance	9
Insurance contract or identification number 20226 Number of Individuals Covered 54 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $6,898 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $245,206 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,898 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	34498
Policy instance	10
Insurance contract or identification number 34498 Number of Individuals Covered 64 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $298,531 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277253
Policy instance	11
Insurance contract or identification number 277253 Number of Individuals Covered 949 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $126,950 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,264,166 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $126,950 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226483
Policy instance	12
Insurance contract or identification number 226483 Number of Individuals Covered 92 Insurance policy start date 2012-08-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $2,471 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $166,025 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,471 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12263548
Policy instance	7
Insurance contract or identification number 12263548 Number of Individuals Covered 869 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $2,194 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,194 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.

Potentially related plans

• HARBOR VIEW, INC. CASH BALANCE PENSION PLAN [EIN = 161285430]
• HARBOR VIEW MEDICAL SERVICES, P.C. CONTRIBUTION RETIREMENT PLAN [EIN = 264517010]
• HARBOR VIEW ADVISORS 401(K) PROFIT SHARING PLAN [EIN = 270505590]
• HARBOR VIEW TRANSPORTATION OF 401 K PROFIT SHARING PLAN TRUST [EIN = 133068786]
• HARBOR VIEW DENTAL CARE 401(K) PLAN [EIN = 454215570]
• HARBOR VIEW FARMS 401K PLAN [EIN = 522213956]
• HARBOR VIEW, INC. PROFIT SHARING PLAN [EIN = 161285430]
• HARBOR VIEW HOLDINGS HEALTH AND WELFARE PLAN [EIN = 931189544]
• HARBOR VIEW ADVISORS 401(K) PROFIT SHARING PLAN [EIN = 270505590]
• HARBOR VIEW CUSTOM CABINETS & INTERIORS LLC RETIREMENT PLAN [EIN = 200696398]
• HARBOR VIEW ADVISORS CASH BALANCE PENSION PLAN [EIN = 270505590]
• HARBOR VIEW DENTISTRY 401(K) PLAN [EIN = 815016142]
• HARBOR VIEW DENTISTRY SAVINGS & RETIREMENT PLAN [EIN = 874455363]