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JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 401k Plan overview

Plan NameJEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN
Plan identification number 502

JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

JEWISH FAMILY SERVICE OF LOS ANGELES has sponsored the creation of one or more 401k plans.

Company Name:JEWISH FAMILY SERVICE OF LOS ANGELES
Employer identification number (EIN):951691013
NAIC Classification:624100
NAIC Description: Individual and Family Services

Additional information about JEWISH FAMILY SERVICE OF LOS ANGELES

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: C0086812

More information about JEWISH FAMILY SERVICE OF LOS ANGELES

Form 5500 Filing Information

Submission information for form 5500 for 401k plan JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022021-07-01
5022020-07-01DAWN WALLACE2022-01-25
5022019-07-01DAWN WALLACE2020-10-13
5022018-07-01DAVID FELMAN2020-01-16
5022017-07-01
5022016-07-01
5022015-07-01ERIKA GRANT
5022014-07-01ERIKA GRANT
5022013-07-01KAREN HILFMAN
5022012-07-01KAREN HILFMAN
5022011-07-01KAREN HILFMAN

Plan Statistics for JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN

401k plan membership statisitcs for JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN

Measure Date Value
2021: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-07-01217
Total number of active participants reported on line 7a of the Form 55002021-07-01226
Number of retired or separated participants receiving benefits2021-07-010
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-01226
2020: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-07-01229
Total number of active participants reported on line 7a of the Form 55002020-07-01217
Number of retired or separated participants receiving benefits2020-07-010
Number of other retired or separated participants entitled to future benefits2020-07-010
Total of all active and inactive participants2020-07-01217
Number of employers contributing to the scheme2020-07-010
2019: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-07-01228
Total number of active participants reported on line 7a of the Form 55002019-07-01228
Number of retired or separated participants receiving benefits2019-07-011
Number of other retired or separated participants entitled to future benefits2019-07-010
Total of all active and inactive participants2019-07-01229
Number of employers contributing to the scheme2019-07-010
2018: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-07-01336
Total number of active participants reported on line 7a of the Form 55002018-07-01336
Number of retired or separated participants receiving benefits2018-07-010
Number of other retired or separated participants entitled to future benefits2018-07-010
Total of all active and inactive participants2018-07-01336
Number of employers contributing to the scheme2018-07-010
2017: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-07-01220
Total number of active participants reported on line 7a of the Form 55002017-07-01220
Number of retired or separated participants receiving benefits2017-07-010
Number of other retired or separated participants entitled to future benefits2017-07-010
Total of all active and inactive participants2017-07-01220
2016: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-07-01324
Total number of active participants reported on line 7a of the Form 55002016-07-01302
Number of retired or separated participants receiving benefits2016-07-011
Number of other retired or separated participants entitled to future benefits2016-07-016
Total of all active and inactive participants2016-07-01309
2015: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-07-01195
Total number of active participants reported on line 7a of the Form 55002015-07-01138
Number of retired or separated participants receiving benefits2015-07-014
Number of other retired or separated participants entitled to future benefits2015-07-019
Total of all active and inactive participants2015-07-01151
2014: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-07-01185
Total number of active participants reported on line 7a of the Form 55002014-07-01192
Number of retired or separated participants receiving benefits2014-07-013
Number of other retired or separated participants entitled to future benefits2014-07-010
Total of all active and inactive participants2014-07-01195
2013: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-07-01253
Total number of active participants reported on line 7a of the Form 55002013-07-01224
Number of retired or separated participants receiving benefits2013-07-014
Number of other retired or separated participants entitled to future benefits2013-07-010
Total of all active and inactive participants2013-07-01228
2012: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-07-01254
Total number of active participants reported on line 7a of the Form 55002012-07-01253
Number of retired or separated participants receiving benefits2012-07-010
Number of other retired or separated participants entitled to future benefits2012-07-010
Total of all active and inactive participants2012-07-01253
2011: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-07-01274
Total number of active participants reported on line 7a of the Form 55002011-07-01254
Number of retired or separated participants receiving benefits2011-07-010
Number of other retired or separated participants entitled to future benefits2011-07-010
Total of all active and inactive participants2011-07-01254

Form 5500 Responses for JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN

2021: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Submission has been amendedNo
2021-07-01This submission is the final filingNo
2021-07-01This return/report is a short plan year return/report (less than 12 months)No
2021-07-01Plan is a collectively bargained planNo
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan benefit arrangement – InsuranceYes
2020: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan benefit arrangement – InsuranceYes
2019: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – InsuranceYes
2018: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan benefit arrangement – InsuranceYes
2017: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – InsuranceYes
2016: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-07-01Type of plan entitySingle employer plan
2016-07-01Submission has been amendedNo
2016-07-01This submission is the final filingNo
2016-07-01This return/report is a short plan year return/report (less than 12 months)No
2016-07-01Plan is a collectively bargained planNo
2016-07-01Plan funding arrangement – InsuranceYes
2016-07-01Plan benefit arrangement – InsuranceYes
2015: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01Submission has been amendedNo
2015-07-01This submission is the final filingNo
2015-07-01This return/report is a short plan year return/report (less than 12 months)No
2015-07-01Plan is a collectively bargained planNo
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – InsuranceYes
2014: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01Submission has been amendedNo
2014-07-01This submission is the final filingNo
2014-07-01This return/report is a short plan year return/report (less than 12 months)No
2014-07-01Plan is a collectively bargained planNo
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – InsuranceYes
2013: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-07-01Type of plan entitySingle employer plan
2013-07-01Submission has been amendedNo
2013-07-01This submission is the final filingNo
2013-07-01This return/report is a short plan year return/report (less than 12 months)No
2013-07-01Plan is a collectively bargained planNo
2013-07-01Plan funding arrangement – General assets of the sponsorYes
2013-07-01Plan benefit arrangement – InsuranceYes
2013-07-01Plan benefit arrangement – General assets of the sponsorYes
2012: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-07-01Type of plan entitySingle employer plan
2012-07-01Submission has been amendedNo
2012-07-01This submission is the final filingNo
2012-07-01This return/report is a short plan year return/report (less than 12 months)No
2012-07-01Plan is a collectively bargained planNo
2012-07-01Plan funding arrangement – General assets of the sponsorYes
2012-07-01Plan benefit arrangement – InsuranceYes
2012-07-01Plan benefit arrangement – General assets of the sponsorYes
2011: JEWISH FAMILY SERVICE OF LOS ANGELES WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-07-01Type of plan entitySingle employer plan
2011-07-01Submission has been amendedNo
2011-07-01This submission is the final filingNo
2011-07-01This return/report is a short plan year return/report (less than 12 months)No
2011-07-01Plan is a collectively bargained planNo
2011-07-01Plan funding arrangement – General assets of the sponsorYes
2011-07-01Plan benefit arrangement – InsuranceYes
2011-07-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00575181
Policy instance 4
Insurance contract or identification number00575181
Number of Individuals Covered223
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $32,414
Total amount of fees paid to insurance companyUSD $11,378
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS & HOSPITAL
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $281,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,148
Amount paid for insurance broker fees11378
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number927969
Policy instance 3
Insurance contract or identification number927969
Number of Individuals Covered202
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $111,767
Total amount of fees paid to insurance companyUSD $3,960
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,882,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $111,767
Insurance broker organization code?3
Amount paid for insurance broker fees3960
Additional information about fees paid to insurance brokerBONUS
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5395886
Policy instance 2
Insurance contract or identification number5395886
Number of Individuals Covered156
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $13,212
Total amount of fees paid to insurance companyUSD $2,727
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $72,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,909
Amount paid for insurance broker fees1497
Additional information about fees paid to insurance brokerSUPPLEMENTAL & NON-MONETARY COMPENSATION AND MARKETING FEES
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number5395886
Policy instance 1
Insurance contract or identification number5395886
Number of Individuals Covered112
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $3,364
Total amount of fees paid to insurance companyUSD $659
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,523
Amount paid for insurance broker fees345
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0071272
Policy instance 1
Insurance contract or identification numberW0071272
Number of Individuals Covered195
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $12
Total amount of fees paid to insurance companyUSD $71,912
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,937,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8
Amount paid for insurance broker fees39883
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number575181
Policy instance 2
Insurance contract or identification number575181
Number of Individuals Covered219
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $31,631
Total amount of fees paid to insurance companyUSD $11,163
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, ACCIDENT, CRITICAL ILLNESS, AND HOSPITAL INDEMNITY
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $296,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,022
Amount paid for insurance broker fees11163
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number575181
Policy instance 2
Insurance contract or identification number575181
Number of Individuals Covered206
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $13,417
Total amount of fees paid to insurance companyUSD $5,626
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $129,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $12,925
Amount paid for insurance broker fees5626
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0071272
Policy instance 1
Insurance contract or identification numberW0071272
Number of Individuals Covered200
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $86,767
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,633,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees86767
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number422124
Policy instance 3
Insurance contract or identification number422124
Number of Individuals Covered217
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $12,194
Total amount of fees paid to insurance companyUSD $2,463
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $184,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,137
Amount paid for insurance broker fees2463
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number281300
Policy instance 1
Insurance contract or identification number281300
Number of Individuals Covered248
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $105,195
Total amount of fees paid to insurance companyUSD $7,153
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,904,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $105,195
Amount paid for insurance broker fees7153
Additional information about fees paid to insurance brokerEDUCATION COMMUNICATION AND TRAINING
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number422124
Policy instance 2
Insurance contract or identification number422124
Number of Individuals Covered216
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $10,546
Total amount of fees paid to insurance companyUSD $2,888
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $142,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,546
Amount paid for insurance broker fees2888
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number281300
Policy instance 1
Insurance contract or identification number281300
Number of Individuals Covered271
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $94,867
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,774,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $94,867
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number422124
Policy instance 2
Insurance contract or identification number422124
Number of Individuals Covered227
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $10,603
Total amount of fees paid to insurance companyUSD $1,630
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $135,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,603
Amount paid for insurance broker fees1630
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number422125
Policy instance 3
Insurance contract or identification number422125
Number of Individuals Covered224
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $10,642
Total amount of fees paid to insurance companyUSD $1,445
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $127,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,642
Amount paid for insurance broker fees1445
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameBURNHAM BENEFITS INSURANCE SERVICES
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberYW148
Policy instance 1
Insurance contract or identification numberYW148
Number of Individuals Covered2
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $173
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $1,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $59
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number281300
Policy instance 2
Insurance contract or identification number281300
Number of Individuals Covered279
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $84,964
Total amount of fees paid to insurance companyUSD $6,630
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,720,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $84,964
Amount paid for insurance broker fees6630
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameBURNHAM BENEFITS INSURANCE SERVICES
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number805122HNO
Policy instance 3
Insurance contract or identification number805122HNO
Number of Individuals Covered178
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $73,955
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,440,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,381
Insurance broker organization code?3
Insurance broker namePLANSOURCE HOLDINGS INC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number805122
Policy instance 2
Insurance contract or identification number805122
Number of Individuals Covered324
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $15,345
Total amount of fees paid to insurance companyUSD $68
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $213,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,880
Insurance broker organization code?3
Amount paid for insurance broker fees68
Additional information about fees paid to insurance brokerINDIRECT COMPENSATION
Insurance broker nameLIFE PLANS, INC.
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberYW148
Policy instance 1
Insurance contract or identification numberYW148
Number of Individuals Covered5
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $661
Total amount of fees paid to insurance companyUSD $119
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHOSPITAL, CANCER, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $286
Amount paid for insurance broker fees89
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameKANDI M MCINTYRE
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberYW148
Policy instance 2
Insurance contract or identification numberYW148
Number of Individuals Covered5
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $931
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCANCER ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $302
Insurance broker organization code?3
Insurance broker nameGAIL B. SILVER
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number755351
Policy instance 1
Insurance contract or identification number755351
Number of Individuals Covered369
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $96,034
Total amount of fees paid to insurance companyUSD $3,000
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,816,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $96,034
Insurance broker organization code?3
Amount paid for insurance broker fees3000
Additional information about fees paid to insurance brokerBONUS
Insurance broker nameLIFE PLANS, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number755351
Policy instance 1
Insurance contract or identification number755351
Number of Individuals Covered389
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $85,660
Total amount of fees paid to insurance companyUSD $6,615
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,759,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $85,660
Amount paid for insurance broker fees6615
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameBURNHAM BENEFITS INSURANCE SERVICES
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberYW148
Policy instance 2
Insurance contract or identification numberYW148
Number of Individuals Covered7
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $439
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCANCER/CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $131
Insurance broker organization code?3
Insurance broker nameDAVID NELSON
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number76463
Policy instance 1
Insurance contract or identification number76463
Number of Individuals Covered150
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $2,060
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $41,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,060
Insurance broker organization code?3
Insurance broker nameBURNHAM BENEFITS INSURANCE SERVICES
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberYW148
Policy instance 2
Insurance contract or identification numberYW148
Number of Individuals Covered7
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $481
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCANCER/CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $101
Insurance broker organization code?3
Insurance broker nameGEOFFREY MALAIS
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number04614
Policy instance 3
Insurance contract or identification number04614
Number of Individuals Covered43
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $3,047
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $60,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,047
Insurance broker organization code?3
Insurance broker nameBURNHAM BENEFITS INSURANCE SERVICES
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number275980
Policy instance 4
Insurance contract or identification number275980
Number of Individuals Covered253
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $79,816
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,589,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $79,816
Insurance broker organization code?3
Insurance broker nameBURNHAM BENEFITS INSURANCE SERVICES
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number04614
Policy instance 4
Insurance contract or identification number04614
Number of Individuals Covered46
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $3,273
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $65,618
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 number76463
Policy instance 1
Insurance contract or identification number76463
Number of Individuals Covered148
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $1,825
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $36,512
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 number275980
Policy instance 2
Insurance contract or identification number275980
Number of Individuals Covered254
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $79,164
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,569,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberYW148
Policy instance 3
Insurance contract or identification numberYW148
Number of Individuals Covered6
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $392
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCANCER/CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberYW148
Policy instance 3
Insurance contract or identification numberYW148
Number of Individuals Covered7
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $568
Total amount of fees paid to insurance companyUSD $36
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY BENEFITS HOSPITAL, CANCER
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,248
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 number275980
Policy instance 1
Insurance contract or identification number275980
Number of Individuals Covered349
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $70,084
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,394,281
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 number06463-0001
Policy instance 2
Insurance contract or identification number06463-0001
Number of Individuals Covered183
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $5,239
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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