401k Plan data: FIRST CITY CREDIT UNION BENEFIT PLAN plan

FIRST CITY CREDIT UNION BENEFIT PLAN 401k Plan overview

Plan Name	FIRST CITY CREDIT UNION BENEFIT PLAN
Plan identification number	501

FIRST CITY CREDIT UNION BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

FIRST CITY CREDIT UNION has sponsored the creation of one or more 401k plans.

Company Name: FIRST CITY CREDIT UNION

Employer identification number (EIN): 951679662

NAIC Classification: 522130
NAIC Description: Credit Unions

Additional information about FIRST CITY CREDIT UNION

Jurisdiction of Incorporation: California Department of State

Incorporation Date: 2002-07-02

Company Identification Number: C2421890

Legal Registered Office Address: 717 W Temple St

Los Angeles
United States of America (USA)
90012

More information about FIRST CITY CREDIT UNION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIRST CITY CREDIT UNION BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 MARY RUBIO MARY RUBIO 2019-07-16
501 2017-01-01 MARY RUBIO MARY RUBIO 2018-06-18
501 2016-01-01 MARY RUBIO MARY RUBIO 2017-06-27
501 2015-01-01 MARY RUBIO 2016-07-29 MARY RUBIO 2016-07-28
501 2014-01-01 MARY RUBIO MARY RUBIO 2015-07-30
501 2013-01-01 MARY RUBIO MARY RUBIO 2014-06-12
501 2012-01-01 MARY RUBIO
501 2011-01-01 MARY RUBIO
501 2010-01-01 MARY RUBIO

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01	MARY RUBIO		MARY RUBIO	2019-07-16
501	2017-01-01	MARY RUBIO		MARY RUBIO	2018-06-18
501	2016-01-01	MARY RUBIO		MARY RUBIO	2017-06-27
501	2015-01-01	MARY RUBIO	2016-07-29	MARY RUBIO	2016-07-28
501	2014-01-01	MARY RUBIO		MARY RUBIO	2015-07-30
501	2013-01-01	MARY RUBIO		MARY RUBIO	2014-06-12
501	2012-01-01	MARY RUBIO
501	2011-01-01	MARY RUBIO
501	2010-01-01	MARY RUBIO

Plan Statistics for FIRST CITY CREDIT UNION BENEFIT PLAN

401k plan membership statisitcs for FIRST CITY CREDIT UNION BENEFIT PLAN

Measure Date Value
2022: FIRST CITY CREDIT UNION BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 120
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 98
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 98
2021: FIRST CITY CREDIT UNION BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 97
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 120
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 120
2020: FIRST CITY CREDIT UNION BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 113
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 97
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 97
2019: FIRST CITY CREDIT UNION BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 122
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 146
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 146
2018: FIRST CITY CREDIT UNION BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 122
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 122
2017: FIRST CITY CREDIT UNION BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 129
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 129
2016: FIRST CITY CREDIT UNION BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 113
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 110
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 110
2015: FIRST CITY CREDIT UNION BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 131
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 113
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 113
2014: FIRST CITY CREDIT UNION BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 131
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 131
2013: FIRST CITY CREDIT UNION BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 123
Total of all active and inactive participants 2013-01-01 123
2012: FIRST CITY CREDIT UNION BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 123
Total of all active and inactive participants 2012-01-01 123
2011: FIRST CITY CREDIT UNION BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 129
Total of all active and inactive participants 2011-01-01 129
2010: FIRST CITY CREDIT UNION BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 112
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 133
Total of all active and inactive participants 2010-01-01 133

Measure	Date	Value
2022: FIRST CITY CREDIT UNION BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	120
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	98
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	98
2021: FIRST CITY CREDIT UNION BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	97
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	120
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	120
2020: FIRST CITY CREDIT UNION BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	113
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	97
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	97
2019: FIRST CITY CREDIT UNION BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	122
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	146
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	146
2018: FIRST CITY CREDIT UNION BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	122
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	122
2017: FIRST CITY CREDIT UNION BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	129
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	129
2016: FIRST CITY CREDIT UNION BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	113
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	110
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	110
2015: FIRST CITY CREDIT UNION BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	131
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	113
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	113
2014: FIRST CITY CREDIT UNION BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	131
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	131
2013: FIRST CITY CREDIT UNION BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	123
Total of all active and inactive participants	2013-01-01	123
2012: FIRST CITY CREDIT UNION BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	123
Total of all active and inactive participants	2012-01-01	123
2011: FIRST CITY CREDIT UNION BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	129
Total of all active and inactive participants	2011-01-01	129
2010: FIRST CITY CREDIT UNION BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	112
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	133
Total of all active and inactive participants	2010-01-01	133

Form 5500 Responses for FIRST CITY CREDIT UNION BENEFIT PLAN

2022: FIRST CITY CREDIT UNION BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: FIRST CITY CREDIT UNION BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: FIRST CITY CREDIT UNION BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: FIRST CITY CREDIT UNION BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: FIRST CITY CREDIT UNION BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: FIRST CITY CREDIT UNION BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: FIRST CITY CREDIT UNION BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: FIRST CITY CREDIT UNION BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: FIRST CITY CREDIT UNION BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: FIRST CITY CREDIT UNION BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: FIRST CITY CREDIT UNION BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: FIRST CITY CREDIT UNION BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: FIRST CITY CREDIT UNION BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BDZZ

Policy instance

Insurance contract or identification number	GLTD0BDZZ
Number of Individuals Covered	98
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $4,027
Total amount of fees paid to insurance company	USD $1,336
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,027
Amount paid for insurance broker fees	1336
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

08369-00163

Policy instance

Insurance contract or identification number	08369-00163
Number of Individuals Covered	149
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,602
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,602
Insurance broker organization code?	3

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	118
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $183
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $3,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $183
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

71616-00062

Policy instance

Insurance contract or identification number	71616-00062
Number of Individuals Covered	36
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $607
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $607
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

00115768

Policy instance

Insurance contract or identification number	00115768
Number of Individuals Covered	368
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,223
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,223
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BDZZ

Policy instance

Insurance contract or identification number	GLUG0BDZZ
Number of Individuals Covered	98
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $6,960
Total amount of fees paid to insurance company	USD $2,339
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $34,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,960
Amount paid for insurance broker fees	2339
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

0149949

Policy instance

Insurance contract or identification number	0149949
Number of Individuals Covered	115
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $45,284
Welfare Benefit Premiums Paid to Carrier	USD $894,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,735
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0149949

Policy instance

Insurance contract or identification number	0149949
Number of Individuals Covered	6
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $2,686
Total amount of fees paid to insurance company	USD $2,440
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,238
Amount paid for insurance broker fees	2440
Additional information about fees paid to insurance broker	2021 PINNACLE MEDICAL RETENTION INCENTIVE RISK
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

892054G

Policy instance

Insurance contract or identification number	892054G
Number of Individuals Covered	94
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $198
Total amount of fees paid to insurance company	USD $197
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD-BAS
Welfare Benefit Premiums Paid to Carrier	USD $1,976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $198
Insurance broker organization code?	3
Amount paid for insurance broker fees	99
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

892054G

Policy instance

Insurance contract or identification number	892054G
Number of Individuals Covered	95
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $242
Total amount of fees paid to insurance company	USD $127
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD-BAS
Welfare Benefit Premiums Paid to Carrier	USD $2,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $242
Amount paid for insurance broker fees	6
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

08369-00163

Policy instance

Insurance contract or identification number	08369-00163
Number of Individuals Covered	137
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,347
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,347
Insurance broker organization code?	3

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	123
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $213
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $4,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $213
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

71616-00062

Policy instance

Insurance contract or identification number	71616-00062
Number of Individuals Covered	37
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $669
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $669
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

00115768

Policy instance

Insurance contract or identification number	00115768
Number of Individuals Covered	455
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,776
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,776
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BDZZ

Policy instance

Insurance contract or identification number	G000BDZZ
Number of Individuals Covered	92
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $3,817
Total amount of fees paid to insurance company	USD $1,442
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,817
Amount paid for insurance broker fees	1442
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BDZZ

Policy instance

Insurance contract or identification number	G000BDZZ
Number of Individuals Covered	92
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $6,682
Total amount of fees paid to insurance company	USD $2,470
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $33,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,682
Amount paid for insurance broker fees	2470
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

0149949

Policy instance

Insurance contract or identification number	0149949
Number of Individuals Covered	120
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $46,125
Welfare Benefit Premiums Paid to Carrier	USD $840,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,436
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0149949

Policy instance

Insurance contract or identification number	0149949
Number of Individuals Covered	4
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $6,404
Total amount of fees paid to insurance company	USD $3,864
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,373
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,981
Amount paid for insurance broker fees	3864
Additional information about fees paid to insurance broker	2020 PINNACLE MEDICAL NEW BUSINESS
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

71616

Policy instance

Insurance contract or identification number	71616
Number of Individuals Covered	481
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,888
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,888

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	107
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

08369-00163

Policy instance

Insurance contract or identification number	08369-00163
Number of Individuals Covered	152
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,268
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,268
Insurance broker organization code?	3

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	121
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $240
Other welfare benefits provided	OTHER (SPECIFY) EAP
Welfare Benefit Premiums Paid to Carrier	USD $4,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $240
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

71616-0062

Policy instance

Insurance contract or identification number	71616-0062
Number of Individuals Covered	33
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $527
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $527
Insurance broker organization code?	3

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	132
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $46,481
Total amount of fees paid to insurance company	USD $2,368
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $972,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,481
Amount paid for insurance broker fees	2368
Additional information about fees paid to insurance broker	BONUS & OVERRIDE NON MONETARY COMPENSATION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

00115768-1080

Policy instance

Insurance contract or identification number	00115768-1080
Number of Individuals Covered	102
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $591
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $591
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BDZZ

Policy instance

Insurance contract or identification number	G000BDZZ
Number of Individuals Covered	96
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $7,057
Total amount of fees paid to insurance company	USD $2,371
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (AD&D)
Welfare Benefit Premiums Paid to Carrier	USD $35,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,057
Amount paid for insurance broker fees	2371
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

0149949

Policy instance

Insurance contract or identification number	0149949
Number of Individuals Covered	137
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,039
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $204,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,866
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0149949

Policy instance

Insurance contract or identification number	0149949
Number of Individuals Covered	4
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $362
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $302
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BDZZ

Policy instance

Insurance contract or identification number	G000BDZZ
Number of Individuals Covered	95
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $4,121
Total amount of fees paid to insurance company	USD $1,400
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,121
Amount paid for insurance broker fees	1400
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

08369-00163

Policy instance

Insurance contract or identification number	08369-00163
Number of Individuals Covered	163
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,238
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,238
Insurance broker organization code?	3

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	5
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	125
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $240
Other welfare benefits provided	OTHER (SPECIFY) EAP
Welfare Benefit Premiums Paid to Carrier	USD $4,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $240
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

71616-0062

Policy instance

Insurance contract or identification number	71616-0062
Number of Individuals Covered	31
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $467
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $467
Insurance broker organization code?	3

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	146
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $39,103
Total amount of fees paid to insurance company	USD $638
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $906,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,103
Amount paid for insurance broker fees	638
Additional information about fees paid to insurance broker	BONUS & OVERRIDE NON MONETARY COMPENSATION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

00115768-1080

Policy instance

Insurance contract or identification number	00115768-1080
Number of Individuals Covered	108
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $681
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $681

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BDZZ

Policy instance

Insurance contract or identification number	G000BDZZ
Number of Individuals Covered	112
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $4,001
Total amount of fees paid to insurance company	USD $455
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,001
Insurance broker organization code?	3
Amount paid for insurance broker fees	455
Additional information about fees paid to insurance broker	OTHER COMPENSATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BDZZ

Policy instance

Insurance contract or identification number	G000BDZZ
Number of Individuals Covered	112
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $6,774
Total amount of fees paid to insurance company	USD $792
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (AD&D)
Welfare Benefit Premiums Paid to Carrier	USD $33,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,774
Insurance broker organization code?	3
Amount paid for insurance broker fees	792
Additional information about fees paid to insurance broker	OTHER COMPENSATION

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	111
Insurance policy end date	2018-09-30
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

08369-00163

Policy instance

Insurance contract or identification number	08369-00163
Number of Individuals Covered	133
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,196
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,983
Insurance broker organization code?	3

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	127
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $243
Other welfare benefits provided	OTHER (SPECIFY) EAP
Welfare Benefit Premiums Paid to Carrier	USD $4,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $243
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

71616-0062

Policy instance

Insurance contract or identification number	71616-0062
Number of Individuals Covered	32
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $237
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $191
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

24654

Policy instance

Insurance contract or identification number	24654
Number of Individuals Covered	108
Insurance policy start date	2018-01-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $3,096
Total amount of fees paid to insurance company	USD $26
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (SPECIFY) AD&D
Welfare Benefit Premiums Paid to Carrier	USD $37,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,096
Insurance broker organization code?	3
Amount paid for insurance broker fees	26
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	137
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $35,442
Total amount of fees paid to insurance company	USD $2,428
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $881,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,505
Additional information about fees paid to insurance broker	BONUS & OVERRIDE NON MONETARY COMPENSATION
Insurance broker organization code?	3
Amount paid for insurance broker fees	2428

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

00115768-1080

Policy instance

Insurance contract or identification number	00115768-1080
Number of Individuals Covered	106
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,113
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BDZZ

Policy instance

Insurance contract or identification number	G000BDZZ
Number of Individuals Covered	112
Insurance policy start date	2018-09-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $1,308
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,308
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BDZZ

Policy instance

Insurance contract or identification number	G000BDZZ
Number of Individuals Covered	112
Insurance policy start date	2018-09-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $2,209
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (AD&D)
Welfare Benefit Premiums Paid to Carrier	USD $11,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,209
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

00115768-1080

Policy instance

Insurance contract or identification number	00115768-1080
Number of Individuals Covered	107
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,661
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

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	133
Insurance policy start date	2016-10-01
Insurance policy end date	2017-09-30
Total amount of commissions paid to insurance broker	USD $34,828
Total amount of fees paid to insurance company	USD $3,531
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $928,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,828
Amount paid for insurance broker fees	3238
Additional information about fees paid to insurance broker	BONUS & OVERRIDE NON MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INSURANCE

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	107
Insurance policy start date	2016-10-01
Insurance policy end date	2017-09-30
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

08369-00163

Policy instance

Insurance contract or identification number	08369-00163
Number of Individuals Covered	102
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,693
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,693
Insurance broker organization code?	3
Insurance broker name	DIGITAL INSURANCE INC

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Insurance policy start date	2016-06-01
Insurance policy end date	2017-05-31
Total amount of commissions paid to insurance broker	USD $245
Other welfare benefits provided	OTHER (SPECIFY) EAP
Welfare Benefit Premiums Paid to Carrier	USD $4,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $245
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INSURANCE

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

71616-0062

Policy instance

Insurance contract or identification number	71616-0062
Number of Individuals Covered	32
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $26
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26
Insurance broker organization code?	3
Insurance broker name	DIGITAL INSURANCE INC

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

24654

Policy instance

Insurance contract or identification number	24654
Number of Individuals Covered	114
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,408
Total amount of fees paid to insurance company	USD $42
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (SPECIFY) AD&D
Welfare Benefit Premiums Paid to Carrier	USD $111,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,851
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSIONS
Amount paid for insurance broker fees	42
Insurance broker name	AXA ASSISTANCE, USA

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	89
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $35,236
Total amount of fees paid to insurance company	USD $1,310
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $797,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,236
Amount paid for insurance broker fees	621
Additional information about fees paid to insurance broker	BONUS & OVERRIDE NON MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS INC

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

24654

Policy instance

Insurance contract or identification number	24654
Number of Individuals Covered	109
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

24654

Policy instance

Insurance contract or identification number	24654
Number of Individuals Covered	112
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

24654

Policy instance

Insurance contract or identification number	24654
Number of Individuals Covered	112
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,190
Total amount of fees paid to insurance company	USD $3,213
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,190
Insurance broker organization code?	3
Amount paid for insurance broker fees	3173
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSIONS
Insurance broker name	AXA ASSISTANCE, USA

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

01616-0062

Policy instance

Insurance contract or identification number	01616-0062
Number of Individuals Covered	42
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $33
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33
Insurance broker organization code?	3
Insurance broker name	DIGITAL INSURANCE INC

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	130
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $246
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $4,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $246
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INSURANCE

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

08369-00163

Policy instance

Insurance contract or identification number	08369-00163
Number of Individuals Covered	139
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,326
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $83,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,326
Insurance broker organization code?	3
Insurance broker name	DDC BROKER - DIGITAL INSURANCE

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	339
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,163
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: 54682 )

Policy contract number

00115768-1080

Policy instance

Insurance contract or identification number	00115768-1080
Number of Individuals Covered	110
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	130
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $239
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $4,810
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $239
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INSURANCE

CUNA MUTUAL GROUP (National Association of Insurance Commissioners NAIC id number: 62626 )

Policy contract number

104-0184-8

Policy instance

Insurance contract or identification number	104-0184-8
Number of Individuals Covered	112
Insurance policy start date	2014-01-01
Insurance policy end date	2014-08-31
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

08369-00163

Policy instance

Insurance contract or identification number	08369-00163
Number of Individuals Covered	131
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,396
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,396
Insurance broker organization code?	3
Insurance broker name	DDC BROKER - DIGITAL INSURANCE

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

00 115768-1080

Policy instance

Insurance contract or identification number	00 115768-1080
Number of Individuals Covered	104
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	CUNA MUTUAL INSURANCE AGENCY

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

01616-0062

Policy instance

Insurance contract or identification number	01616-0062
Number of Individuals Covered	46
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $32
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32
Insurance broker organization code?	3
Insurance broker name	DIGITAL INSURANCE INC

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

24654

Policy instance

Insurance contract or identification number	24654
Number of Individuals Covered	110
Insurance policy start date	2014-09-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,245
Total amount of fees paid to insurance company	USD $10
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,245
Insurance broker organization code?	3
Amount paid for insurance broker fees	10
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION
Insurance broker name	AXA ASSISTANCE, USA

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

24654

Policy instance

Insurance contract or identification number	24654
Number of Individuals Covered	109
Insurance policy start date	2014-09-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

24654

Policy instance

Insurance contract or identification number	24654
Number of Individuals Covered	109
Insurance policy start date	2014-09-01
Insurance policy end date	2014-12-31
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $916
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

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	98
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $32,566
Total amount of fees paid to insurance company	USD $445
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $752,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,566
Amount paid for insurance broker fees	445
Additional information about fees paid to insurance broker	BONUS & OVERRIDE NON MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INSURANCE

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	230
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INSURANCE

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

01616-0062

Policy instance

Insurance contract or identification number	01616-0062
Number of Individuals Covered	20
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $32
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32
Insurance broker organization code?	3
Insurance broker name	CUNA MUTUAL INSURANCE AGENCY

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	123
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $241
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $4,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $241
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INSURANCE

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 54682 )

Policy contract number

00115768-1080

Policy instance

Insurance contract or identification number	00115768-1080
Number of Individuals Covered	102
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	CUNA MUTUAL INS AGENCY

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	112
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $30,249
Total amount of fees paid to insurance company	USD $1,154
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $754,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,249
Amount paid for insurance broker fees	1154
Additional information about fees paid to insurance broker	INCENTIVES, EDUCATION COMMUNICATION & TRAINING
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INSURANCE

CUNA MUTUAL GROUP (National Association of Insurance Commissioners NAIC id number: 62626 )

Policy contract number

104-0184-8

Policy instance

Insurance contract or identification number	104-0184-8
Number of Individuals Covered	108
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

08369

Policy instance

Insurance contract or identification number	08369
Number of Individuals Covered	87
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $288
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $83,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $288
Insurance broker organization code?	3
Insurance broker name	DDC BROKER - DIGITAL INSURANCE

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	123
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $242
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EAP
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $242
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SERVICES

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

08369

Policy instance

Insurance contract or identification number	08369
Number of Individuals Covered	85
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,215
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 $80,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,215
Insurance broker organization code?	3
Insurance broker name	CUNA MUTUAL INSURACE AGENCY

CUNA MUTUAL GROUP (National Association of Insurance Commissioners NAIC id number: 62626 )

Policy contract number

10401848

Policy instance

Insurance contract or identification number	10401848
Number of Individuals Covered	112
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $58,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

01616-0062

Policy instance

Insurance contract or identification number	01616-0062
Number of Individuals Covered	20
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $34
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 $6,827
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
Insurance broker organization code?	3
Insurance broker name	CUNA MUTUAL INSURANCE AGENCY

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 54682 )

Policy contract number

00115768 0191

Policy instance

Insurance contract or identification number	00115768 0191
Number of Individuals Covered	104
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
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	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
Insurance broker organization code?	3
Insurance broker name	CUNA MUTUAL INS AGENCY

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	111
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $27,597
Total amount of fees paid to insurance company	USD $76
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends 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 $590,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,597
Amount paid for insurance broker fees	931
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SERVICES INC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 54682 )

Policy contract number

00115768 0191

Policy instance

Insurance contract or identification number	00115768 0191
Number of Individuals Covered	128
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
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	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

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	129
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $246
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EAP
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

CUNA

Policy instance

Insurance contract or identification number	CUNA
Number of Individuals Covered	23
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $31
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 $6,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CUNA MUTUAL GROUP (National Association of Insurance Commissioners NAIC id number: 62626 )

Policy contract number

10401848

Policy instance

Insurance contract or identification number	10401848
Number of Individuals Covered	109
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
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	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $58,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	110
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $30,066
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $603,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CUNA MUTUAL GROUP (National Association of Insurance Commissioners NAIC id number: 62626 )

Policy contract number

10401848

Policy instance

Insurance contract or identification number	10401848
Number of Individuals Covered	113
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
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	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $51,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

CUNA

Policy instance

Insurance contract or identification number	CUNA
Number of Individuals Covered	23
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $32
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 $6,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

2234

Policy instance

Insurance contract or identification number	2234
Number of Individuals Covered	133
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $212
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EAP
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,243
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: 54682 )

Policy contract number

00115768 0191

Policy instance

Insurance contract or identification number	00115768 0191
Number of Individuals Covered	101
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
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	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

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

C20657

Policy instance

Insurance contract or identification number	C20657
Number of Individuals Covered	90
Insurance policy start date	2009-06-01
Insurance policy end date	2010-06-01
Total amount of commissions paid to insurance broker	USD $27,357
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $542,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	FIRST CITY CREDIT UNION
Employer identification number (EIN):	951679662
NAIC Classification:	522130
NAIC Description:	Credit Unions

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:	2002-07-02
Company Identification Number:	C2421890
Legal Registered Office Address:	717 W Temple St Los Angeles United States of America (USA) 90012