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ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 401k Plan overview

Plan NameALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN
Plan identification number 501

ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

ALBERT A. WEBB ASSOCIATES has sponsored the creation of one or more 401k plans.

Company Name:ALBERT A. WEBB ASSOCIATES
Employer identification number (EIN):951723730
NAIC Classification:541330
NAIC Description:Engineering Services

Additional information about ALBERT A. WEBB ASSOCIATES

Jurisdiction of Incorporation: California Department of State
Incorporation Date: 0000-00-00
Company Identification Number: C0262218
Legal Registered Office Address: 3788 McCray StRiversideCA92506


United States of America (USA)

More information about ALBERT A. WEBB ASSOCIATES

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-10-01KEVIN FERGUSON2024-01-08
5012021-10-01KEVIN FERGUSON2023-02-09
5012020-10-01KEVIN FERGUSON2022-03-18
5012019-10-01KEVIN W. M. FERGUSON2021-03-15
5012018-10-01KEVIN W. M. FERGUSON2020-04-02
5012017-10-01
5012016-10-01KEVIN FERGUSON
5012015-10-01KEVIN FERGUSON
5012014-10-01KEVIN FERGUSON
5012013-10-01KEVIN FERGUSON
5012012-10-01KEVIN FERGUSON
5012011-10-01KEVIN FERGUSON
5012010-10-01KEVIN FERGUSON
5012009-10-01KEVIN FERGUSON
5012008-10-01KEVIN FERGUSON
5012007-10-01KEVIN FERGUSON

Plan Statistics for ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN

401k plan membership statisitcs for ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN

Measure Date Value
2022: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-10-01122
Total number of active participants reported on line 7a of the Form 55002022-10-01128
Number of retired or separated participants receiving benefits2022-10-011
Number of other retired or separated participants entitled to future benefits2022-10-010
Total of all active and inactive participants2022-10-01129
Number of employers contributing to the scheme2022-10-010
2021: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-01151
Total number of active participants reported on line 7a of the Form 55002021-10-01121
Number of retired or separated participants receiving benefits2021-10-010
Number of other retired or separated participants entitled to future benefits2021-10-010
Total of all active and inactive participants2021-10-01121
Number of employers contributing to the scheme2021-10-010
2020: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-10-01125
Total number of active participants reported on line 7a of the Form 55002020-10-01139
Number of retired or separated participants receiving benefits2020-10-012
Number of other retired or separated participants entitled to future benefits2020-10-0110
Total of all active and inactive participants2020-10-01151
Number of employers contributing to the scheme2020-10-010
2019: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-10-01119
Total number of active participants reported on line 7a of the Form 55002019-10-01111
Number of retired or separated participants receiving benefits2019-10-013
Number of other retired or separated participants entitled to future benefits2019-10-010
Total of all active and inactive participants2019-10-01114
Number of employers contributing to the scheme2019-10-010
2018: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-10-01121
Total number of active participants reported on line 7a of the Form 55002018-10-01119
Number of retired or separated participants receiving benefits2018-10-010
Number of other retired or separated participants entitled to future benefits2018-10-010
Total of all active and inactive participants2018-10-01119
Number of employers contributing to the scheme2018-10-010
2017: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-10-01129
Total number of active participants reported on line 7a of the Form 55002017-10-01121
Number of retired or separated participants receiving benefits2017-10-010
Number of other retired or separated participants entitled to future benefits2017-10-010
Total of all active and inactive participants2017-10-01121
2016: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01133
Total number of active participants reported on line 7a of the Form 55002016-10-01125
Number of retired or separated participants receiving benefits2016-10-014
Number of other retired or separated participants entitled to future benefits2016-10-010
Total of all active and inactive participants2016-10-01129
2015: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01130
Total number of active participants reported on line 7a of the Form 55002015-10-01130
Number of retired or separated participants receiving benefits2015-10-013
Number of other retired or separated participants entitled to future benefits2015-10-010
Total of all active and inactive participants2015-10-01133
2014: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-10-01126
Total number of active participants reported on line 7a of the Form 55002014-10-01127
Number of retired or separated participants receiving benefits2014-10-013
Number of other retired or separated participants entitled to future benefits2014-10-010
Total of all active and inactive participants2014-10-01130
2013: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-10-01119
Total number of active participants reported on line 7a of the Form 55002013-10-01123
Number of retired or separated participants receiving benefits2013-10-013
Number of other retired or separated participants entitled to future benefits2013-10-010
Total of all active and inactive participants2013-10-01126
2012: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-10-01118
Total number of active participants reported on line 7a of the Form 55002012-10-01116
Number of retired or separated participants receiving benefits2012-10-013
Number of other retired or separated participants entitled to future benefits2012-10-010
Total of all active and inactive participants2012-10-01119
2011: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-10-01127
Total number of active participants reported on line 7a of the Form 55002011-10-01114
Number of retired or separated participants receiving benefits2011-10-014
Number of other retired or separated participants entitled to future benefits2011-10-010
Total of all active and inactive participants2011-10-01118
2010: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-10-01108
Total number of active participants reported on line 7a of the Form 55002010-10-01122
Number of retired or separated participants receiving benefits2010-10-015
Number of other retired or separated participants entitled to future benefits2010-10-010
Total of all active and inactive participants2010-10-01127
2009: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-10-01128
Total number of active participants reported on line 7a of the Form 55002009-10-01108
Number of retired or separated participants receiving benefits2009-10-010
Number of other retired or separated participants entitled to future benefits2009-10-010
Total of all active and inactive participants2009-10-01108
2008: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year2008-10-01157
Total number of active participants reported on line 7a of the Form 55002008-10-01128
Number of retired or separated participants receiving benefits2008-10-010
Number of other retired or separated participants entitled to future benefits2008-10-010
Total of all active and inactive participants2008-10-01128
2007: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2007 401k membership
Total participants, beginning-of-year2007-10-01168
Total number of active participants reported on line 7a of the Form 55002007-10-01157
Number of retired or separated participants receiving benefits2007-10-010
Number of other retired or separated participants entitled to future benefits2007-10-010
Total of all active and inactive participants2007-10-01157

Form 5500 Responses for ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN

2022: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-10-01Type of plan entitySingle employer plan
2022-10-01Plan funding arrangement – InsuranceYes
2022-10-01Plan benefit arrangement – InsuranceYes
2021: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – InsuranceYes
2020: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – InsuranceYes
2019: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – InsuranceYes
2018: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – InsuranceYes
2017: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Submission has been amendedNo
2017-10-01This submission is the final filingNo
2017-10-01This return/report is a short plan year return/report (less than 12 months)No
2017-10-01Plan is a collectively bargained planNo
2017-10-01Plan funding arrangement – General assets of the sponsorYes
2017-10-01Plan benefit arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – General assets of the sponsorYes
2016: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)No
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – General assets of the sponsorYes
2016-10-01Plan benefit arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – General assets of the sponsorYes
2015: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – General assets of the sponsorYes
2015-10-01Plan benefit arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – General assets of the sponsorYes
2014: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-10-01Type of plan entitySingle employer plan
2014-10-01Submission has been amendedNo
2014-10-01This submission is the final filingNo
2014-10-01This return/report is a short plan year return/report (less than 12 months)No
2014-10-01Plan is a collectively bargained planNo
2014-10-01Plan funding arrangement – General assets of the sponsorYes
2014-10-01Plan benefit arrangement – InsuranceYes
2013: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-10-01Type of plan entitySingle employer plan
2013-10-01Submission has been amendedNo
2013-10-01This submission is the final filingNo
2013-10-01This return/report is a short plan year return/report (less than 12 months)No
2013-10-01Plan is a collectively bargained planNo
2013-10-01Plan funding arrangement – General assets of the sponsorYes
2013-10-01Plan benefit arrangement – InsuranceYes
2012: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-10-01Type of plan entitySingle employer plan
2012-10-01Submission has been amendedNo
2012-10-01This submission is the final filingNo
2012-10-01This return/report is a short plan year return/report (less than 12 months)No
2012-10-01Plan is a collectively bargained planNo
2012-10-01Plan funding arrangement – General assets of the sponsorYes
2012-10-01Plan benefit arrangement – InsuranceYes
2011: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-10-01Type of plan entitySingle employer plan
2011-10-01Submission has been amendedNo
2011-10-01This submission is the final filingNo
2011-10-01This return/report is a short plan year return/report (less than 12 months)No
2011-10-01Plan is a collectively bargained planNo
2011-10-01Plan funding arrangement – General assets of the sponsorYes
2011-10-01Plan benefit arrangement – InsuranceYes
2010: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-10-01Type of plan entitySingle employer plan
2010-10-01Submission has been amendedNo
2010-10-01This submission is the final filingNo
2010-10-01This return/report is a short plan year return/report (less than 12 months)No
2010-10-01Plan is a collectively bargained planNo
2010-10-01Plan funding arrangement – InsuranceYes
2010-10-01Plan benefit arrangement – InsuranceYes
2009: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-10-01Type of plan entitySingle employer plan
2009-10-01Submission has been amendedNo
2009-10-01This submission is the final filingNo
2009-10-01This return/report is a short plan year return/report (less than 12 months)No
2009-10-01Plan is a collectively bargained planNo
2009-10-01Plan funding arrangement – InsuranceYes
2009-10-01Plan benefit arrangement – InsuranceYes
2008: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2008 form 5500 responses
2008-10-01Type of plan entitySingle employer plan
2008-10-01Submission has been amendedNo
2008-10-01This submission is the final filingNo
2008-10-01This return/report is a short plan year return/report (less than 12 months)No
2008-10-01Plan is a collectively bargained planNo
2008-10-01Plan funding arrangement – InsuranceYes
2008-10-01Plan benefit arrangement – InsuranceYes
2007: ALBERT A. WEBB ASSOCIATES WELFARE BENEFITS PLAN 2007 form 5500 responses
2007-10-01Type of plan entitySingle employer plan
2007-10-01First time form 5500 has been submittedYes
2007-10-01Submission has been amendedNo
2007-10-01This submission is the final filingNo
2007-10-01This return/report is a short plan year return/report (less than 12 months)No
2007-10-01Plan is a collectively bargained planNo
2007-10-01Plan funding arrangement – InsuranceYes
2007-10-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number149013HNO
Policy instance 2
Insurance contract or identification number149013HNO
Number of Individuals Covered229
Insurance policy start date2022-10-01
Insurance policy end date2023-09-30
Total amount of commissions paid to insurance brokerUSD $74,623
Total amount of fees paid to insurance companyUSD $5,000
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,632,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $74,623
Amount paid for insurance broker fees5000
Additional information about fees paid to insurance broker2022 Q4 GROW WITH US NEW BUSINESS INCENTIVE RISK
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number149013
Policy instance 1
Insurance contract or identification number149013
Number of Individuals Covered266
Insurance policy start date2022-10-01
Insurance policy end date2023-09-30
Total amount of commissions paid to insurance brokerUSD $18,317
Total amount of fees paid to insurance companyUSD $12,840
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $326,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $18,317
Amount paid for insurance broker fees12840
Additional information about fees paid to insurance broker2022 PINNACLE DENTAL, MEDICAL AND VISION NEW BUSINESS INCENTIVE RISK
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD129145
Policy instance 3
Insurance contract or identification numberLTD129145
Number of Individuals Covered122
Insurance policy start date2022-10-01
Insurance policy end date2023-09-30
Total amount of commissions paid to insurance brokerUSD $3,409
Total amount of fees paid to insurance companyUSD $374
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,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $22,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,409
Amount paid for insurance broker fees374
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD129145
Policy instance 2
Insurance contract or identification numberLTD129145
Number of Individuals Covered112
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $2,703
Total amount of fees paid to insurance companyUSD $377
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $18,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,703
Amount paid for insurance broker fees377
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number280650
Policy instance 1
Insurance contract or identification number280650
Number of Individuals Covered266
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $95,353
Total amount of fees paid to insurance companyUSD $4,337
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $1,817,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $95,353
Amount paid for insurance broker fees4337
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number280650
Policy instance 1
Insurance contract or identification number280650
Number of Individuals Covered241
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $90,413
Total amount of fees paid to insurance companyUSD $4,778
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $1,702,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $90,413
Amount paid for insurance broker fees4778
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD129145
Policy instance 2
Insurance contract or identification numberLTD129145
Number of Individuals Covered110
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $2,489
Total amount of fees paid to insurance companyUSD $360
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $16,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,489
Amount paid for insurance broker fees360
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number280650
Policy instance 1
Insurance contract or identification number280650
Number of Individuals Covered232
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $86,225
Total amount of fees paid to insurance companyUSD $372
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $1,511,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $86,225
Amount paid for insurance broker fees372
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD129145
Policy instance 3
Insurance contract or identification numberLTD129145
Number of Individuals Covered111
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $2,372
Total amount of fees paid to insurance companyUSD $362
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $15,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,372
Amount paid for insurance broker fees362
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number530074
Policy instance 2
Insurance contract or identification number530074
Number of Individuals Covered92
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $6,116
Total amount of fees paid to insurance companyUSD $2,883
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,720
Amount paid for insurance broker fees2883
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number280650
Policy instance 1
Insurance contract or identification number280650
Number of Individuals Covered245
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $78,705
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $1,563,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $78,705
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number530074
Policy instance 2
Insurance contract or identification number530074
Number of Individuals Covered92
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $6,138
Total amount of fees paid to insurance companyUSD $3,118
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $61,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,138
Amount paid for insurance broker fees3118
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD129145
Policy instance 3
Insurance contract or identification numberLTD129145
Number of Individuals Covered119
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $2,430
Total amount of fees paid to insurance companyUSD $404
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $16,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,430
Amount paid for insurance broker fees404
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD129145
Policy instance 2
Insurance contract or identification numberLTD129145
Number of Individuals Covered120
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $2,495
Total amount of fees paid to insurance companyUSD $62
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $16,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00530074
Policy instance 1
Insurance contract or identification number00530074
Number of Individuals Covered103
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $4,940
Total amount of fees paid to insurance companyUSD $3,272
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $49,396
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 number280650
Policy instance 3
Insurance contract or identification number280650
Number of Individuals Covered121
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $72,672
Total amount of fees paid to insurance companyUSD $189
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 BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,559,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3335070
Policy instance 3
Insurance contract or identification number3335070
Number of Individuals Covered123
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $86,807
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 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 $1,685,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $86,807
Insurance broker organization code?3
Insurance broker nameARTHUR J. GALLAGHER & CO.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK603766
Policy instance 5
Insurance contract or identification numberSOK603766
Number of Individuals Covered130
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $237
Total amount of fees paid to insurance companyUSD $22
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $237
Amount paid for insurance broker fees22
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameARTHUR J. GALLAGHER & CO.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605484
Policy instance 4
Insurance contract or identification numberSGM605484
Number of Individuals Covered130
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $1,442
Total amount of fees paid to insurance companyUSD $160
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $9,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,442
Amount paid for insurance broker fees160
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameARTHUR J. GALLAGHER & CO.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD602548
Policy instance 1
Insurance contract or identification numberSGD602548
Number of Individuals Covered130
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $2,878
Total amount of fees paid to insurance companyUSD $252
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $16,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,536
Amount paid for insurance broker fees252
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameBENEFIT ADVISORS SERVICES
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0806683
Policy instance 2
Insurance contract or identification number0806683
Number of Individuals Covered588
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $1,512
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,512
Insurance broker organization code?3
Insurance broker nameARTHUR J. GALLAGHER & CO.
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3335070
Policy instance 3
Insurance contract or identification number3335070
Number of Individuals Covered121
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $81,034
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 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 $1,564,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,034
Insurance broker organization code?3
Insurance broker nameARTHUR J. GALLAGHER & CO.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0806683
Policy instance 1
Insurance contract or identification number0806683
Number of Individuals Covered290
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $1,418
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,418
Insurance broker organization code?3
Insurance broker nameARTHUR J. GALLAGHER & CO.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK603766
Policy instance 2
Insurance contract or identification numberSOK603766
Number of Individuals Covered127
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $1,659
Total amount of fees paid to insurance companyUSD $309
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,659
Amount paid for insurance broker fees309
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameARTHUR J. GALLAGHER & CO.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD602548
Policy instance 4
Insurance contract or identification numberSGD602548
Number of Individuals Covered127
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $2,842
Total amount of fees paid to insurance companyUSD $205
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $16,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,501
Amount paid for insurance broker fees205
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameBENEFIT ADVISORS SERVICES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605484
Policy instance 5
Insurance contract or identification numberSGM605484
Number of Individuals Covered127
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $221
Total amount of fees paid to insurance companyUSD $41
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $221
Amount paid for insurance broker fees41
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameARTHUR J. GALLAGHER & CO.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number277414
Policy instance 3
Insurance contract or identification number277414
Number of Individuals Covered123
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $80,567
Total amount of fees paid to insurance companyUSD $1,063
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,330,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $80,567
Insurance broker organization code?3
Amount paid for insurance broker fees1063
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameBENEFLEX INSURANCE SERVICES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD602548
Policy instance 1
Insurance contract or identification numberSGD602548
Number of Individuals Covered123
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $2,743
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $16,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,414
Insurance broker organization code?3
Insurance broker nameBENEFIT ADVISORS SERVICES
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3335070
Policy instance 2
Insurance contract or identification number3335070
Number of Individuals Covered122
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $5,517
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $55,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,517
Insurance broker organization code?3
Insurance broker nameE3 FINANCIAL
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number3335070
Policy instance 5
Insurance contract or identification number3335070
Number of Individuals Covered106
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $4,875
Total amount of fees paid to insurance companyUSD $4,880
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 $50,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,875
Amount paid for insurance broker fees4880
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameE3 FINANCIAL
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number277414
Policy instance 3
Insurance contract or identification number277414
Number of Individuals Covered105
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $64,798
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 $1,129,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $64,798
Insurance broker organization code?3
Insurance broker nameE3 FINANCIAL
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK601624
Policy instance 2
Insurance contract or identification numberSOK601624
Number of Individuals Covered113
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $314
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $276
Insurance broker organization code?3
Insurance broker nameALLIANT INSURANCE SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM602638
Policy instance 1
Insurance contract or identification numberSGM602638
Number of Individuals Covered113
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $1,779
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $10,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,566
Insurance broker organization code?3
Insurance broker nameBENEFIT ADVISORS SERVICES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD602548
Policy instance 4
Insurance contract or identification numberSGD602548
Number of Individuals Covered113
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $2,429
Total amount of fees paid to insurance companyUSD $392
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $14,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,138
Amount paid for insurance broker fees392
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameBENEFIT ADVISORS SERVICES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK601624
Policy instance 1
Insurance contract or identification numberSOK601624
Number of Individuals Covered114
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $315
Total amount of fees paid to insurance companyUSD $45
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM602638
Policy instance 2
Insurance contract or identification numberSGM602638
Number of Individuals Covered114
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $1,829
Total amount of fees paid to insurance companyUSD $257
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $10,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number3335070
Policy instance 3
Insurance contract or identification number3335070
Number of Individuals Covered100
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $71,803
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 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 $1,153,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD602548
Policy instance 4
Insurance contract or identification numberSGD602548
Number of Individuals Covered114
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $2,372
Total amount of fees paid to insurance companyUSD $392
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $13,956
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 numberC21653
Policy instance 3
Insurance contract or identification numberC21653
Number of Individuals Covered122
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $55,848
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,098,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKM05774891
Policy instance 2
Insurance contract or identification numberKM05774891
Number of Individuals Covered226
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $2,119
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 $23,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05774891
Policy instance 1
Insurance contract or identification numberKM05774891
Number of Individuals Covered151
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $3,222
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 BenefitYes
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 $36,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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