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HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan NameHEALTH AND WELFARE BENEFIT PLAN
Plan identification number 512

HEALTH AND WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

CUSTOM CONTROL SENSORS, LLC has sponsored the creation of one or more 401k plans.

Company Name:CUSTOM CONTROL SENSORS, LLC
Employer identification number (EIN):951933664
NAIC Classification:334500

Additional information about CUSTOM CONTROL SENSORS, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 5653255

More information about CUSTOM CONTROL SENSORS, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5122022-04-01THOMAS M. PILGRIM2023-08-08
5122021-04-01TOM PILGRIM, CFO2022-10-02 TOM PILGRIM, CFO2022-10-02
5122021-04-01THOMAS M. PILGRIM, CFO2022-10-03 THOMAS M. PILGRIM, CFO2022-10-03
5122020-04-01TOM PILGRIM2021-10-06
5122019-04-01TOM PILGRIM2020-10-14
5122017-04-01
5122016-04-01SHEILA DELA VEGA
5122015-04-01THOMAS PILGRIM
5122014-04-01THOMAS PILGRIM
5122013-04-01THOMAS MARTIN PILGRIM
5122012-04-01THOMAS M. PILGRIM
5122011-04-01THOMAS M. PILGRIM
5122010-04-01THOMAS M. PILGRIM
5122009-04-01THOMAS M. PILGRIM

Plan Statistics for HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2022: HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-04-01119
Total number of active participants reported on line 7a of the Form 55002022-04-01119
Number of retired or separated participants receiving benefits2022-04-010
Number of other retired or separated participants entitled to future benefits2022-04-010
Total of all active and inactive participants2022-04-01119
2021: HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-04-01133
Total number of active participants reported on line 7a of the Form 55002021-04-01119
Number of retired or separated participants receiving benefits2021-04-010
Total of all active and inactive participants2021-04-01119
2020: HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-04-01152
Total number of active participants reported on line 7a of the Form 55002020-04-01133
Number of retired or separated participants receiving benefits2020-04-010
Total of all active and inactive participants2020-04-01133
2019: HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-04-01141
Total number of active participants reported on line 7a of the Form 55002019-04-01149
Number of retired or separated participants receiving benefits2019-04-010
Total of all active and inactive participants2019-04-01149
2017: HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-04-01180
Total number of active participants reported on line 7a of the Form 55002017-04-01165
Number of retired or separated participants receiving benefits2017-04-011
Total of all active and inactive participants2017-04-01166
2016: HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-04-01180
Total number of active participants reported on line 7a of the Form 55002016-04-01179
Number of retired or separated participants receiving benefits2016-04-011
Total of all active and inactive participants2016-04-01180
2015: HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-04-01215
Total number of active participants reported on line 7a of the Form 55002015-04-01178
Number of retired or separated participants receiving benefits2015-04-012
Total of all active and inactive participants2015-04-01180
2014: HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-04-01191
Total number of active participants reported on line 7a of the Form 55002014-04-01209
Total of all active and inactive participants2014-04-01209
2013: HEALTH AND WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-04-01177
Total number of active participants reported on line 7a of the Form 55002013-04-01141
Total of all active and inactive participants2013-04-01141
2012: HEALTH AND WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-04-01146
Total number of active participants reported on line 7a of the Form 55002012-04-01177
Number of retired or separated participants receiving benefits2012-04-010
Number of other retired or separated participants entitled to future benefits2012-04-010
Total of all active and inactive participants2012-04-01177
2011: HEALTH AND WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-04-01123
Total number of active participants reported on line 7a of the Form 55002011-04-01146
Number of retired or separated participants receiving benefits2011-04-010
Number of other retired or separated participants entitled to future benefits2011-04-010
Total of all active and inactive participants2011-04-01146
2010: HEALTH AND WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-04-01124
Total number of active participants reported on line 7a of the Form 55002010-04-01122
Number of retired or separated participants receiving benefits2010-04-011
Number of other retired or separated participants entitled to future benefits2010-04-010
Total of all active and inactive participants2010-04-01123
2009: HEALTH AND WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-04-01104
Total number of active participants reported on line 7a of the Form 55002009-04-01124
Number of retired or separated participants receiving benefits2009-04-010
Number of other retired or separated participants entitled to future benefits2009-04-010
Total of all active and inactive participants2009-04-01124

Form 5500 Responses for HEALTH AND WELFARE BENEFIT PLAN

2022: HEALTH AND WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-04-01Type of plan entitySingle employer plan
2022-04-01Submission has been amendedNo
2022-04-01This submission is the final filingNo
2022-04-01This return/report is a short plan year return/report (less than 12 months)No
2022-04-01Plan is a collectively bargained planNo
2022-04-01Plan funding arrangement – InsuranceYes
2022-04-01Plan benefit arrangement – InsuranceYes
2021: HEALTH AND WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-04-01Type of plan entitySingle employer plan
2021-04-01Submission has been amendedNo
2021-04-01This submission is the final filingNo
2021-04-01This return/report is a short plan year return/report (less than 12 months)No
2021-04-01Plan is a collectively bargained planNo
2021-04-01Plan funding arrangement – InsuranceYes
2021-04-01Plan benefit arrangement – InsuranceYes
2020: HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-04-01Type of plan entitySingle employer plan
2020-04-01Submission has been amendedNo
2020-04-01This submission is the final filingNo
2020-04-01This return/report is a short plan year return/report (less than 12 months)No
2020-04-01Plan is a collectively bargained planNo
2020-04-01Plan funding arrangement – InsuranceYes
2020-04-01Plan benefit arrangement – InsuranceYes
2019: HEALTH AND WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-04-01Type of plan entitySingle employer plan
2019-04-01Submission has been amendedNo
2019-04-01This submission is the final filingNo
2019-04-01This return/report is a short plan year return/report (less than 12 months)No
2019-04-01Plan is a collectively bargained planNo
2019-04-01Plan funding arrangement – InsuranceYes
2019-04-01Plan benefit arrangement – InsuranceYes
2017: HEALTH AND WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-04-01Type of plan entitySingle employer plan
2017-04-01Submission has been amendedNo
2017-04-01This submission is the final filingNo
2017-04-01This return/report is a short plan year return/report (less than 12 months)No
2017-04-01Plan is a collectively bargained planNo
2017-04-01Plan funding arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – InsuranceYes
2016: HEALTH AND WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Submission has been amendedNo
2016-04-01This submission is the final filingNo
2016-04-01This return/report is a short plan year return/report (less than 12 months)No
2016-04-01Plan is a collectively bargained planNo
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – InsuranceYes
2015: HEALTH AND WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)No
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – InsuranceYes
2014: HEALTH AND WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-04-01Type of plan entitySingle employer plan
2014-04-01Submission has been amendedNo
2014-04-01This submission is the final filingNo
2014-04-01This return/report is a short plan year return/report (less than 12 months)No
2014-04-01Plan is a collectively bargained planNo
2014-04-01Plan funding arrangement – InsuranceYes
2014-04-01Plan benefit arrangement – InsuranceYes
2013: HEALTH AND WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-04-01Type of plan entitySingle employer plan
2013-04-01Submission has been amendedNo
2013-04-01This submission is the final filingNo
2013-04-01This return/report is a short plan year return/report (less than 12 months)No
2013-04-01Plan is a collectively bargained planNo
2013-04-01Plan funding arrangement – InsuranceYes
2013-04-01Plan benefit arrangement – InsuranceYes
2012: HEALTH AND WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-04-01Type of plan entitySingle employer plan
2012-04-01Submission has been amendedNo
2012-04-01This submission is the final filingNo
2012-04-01This return/report is a short plan year return/report (less than 12 months)No
2012-04-01Plan is a collectively bargained planNo
2012-04-01Plan funding arrangement – InsuranceYes
2012-04-01Plan benefit arrangement – InsuranceYes
2011: HEALTH AND WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-04-01Type of plan entitySingle employer plan
2011-04-01Submission has been amendedNo
2011-04-01This submission is the final filingNo
2011-04-01This return/report is a short plan year return/report (less than 12 months)No
2011-04-01Plan is a collectively bargained planNo
2011-04-01Plan funding arrangement – InsuranceYes
2011-04-01Plan benefit arrangement – InsuranceYes
2010: HEALTH AND WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-04-01Type of plan entitySingle employer plan
2010-04-01Submission has been amendedNo
2010-04-01This submission is the final filingNo
2010-04-01This return/report is a short plan year return/report (less than 12 months)No
2010-04-01Plan is a collectively bargained planNo
2010-04-01Plan funding arrangement – InsuranceYes
2010-04-01Plan benefit arrangement – InsuranceYes
2009: HEALTH AND WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-04-01Type of plan entitySingle employer plan
2009-04-01Submission has been amendedNo
2009-04-01This submission is the final filingNo
2009-04-01This return/report is a short plan year return/report (less than 12 months)No
2009-04-01Plan is a collectively bargained planNo
2009-04-01Plan funding arrangement – InsuranceYes
2009-04-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 2
Insurance contract or identification number180063
Number of Individuals Covered87
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $40,265
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $834,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,265
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0APB3
Policy instance 7
Insurance contract or identification numberGLTD0APB3
Number of Individuals Covered114
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $3,203
Total amount of fees paid to insurance companyUSD $1,276
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 $21,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,203
Amount paid for insurance broker fees1276
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0APB3
Policy instance 6
Insurance contract or identification numberGLUG0APB3
Number of Individuals Covered118
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $7,757
Total amount of fees paid to insurance companyUSD $2,517
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 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 $37,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,757
Amount paid for insurance broker fees2517
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number907128
Policy instance 5
Insurance contract or identification number907128
Number of Individuals Covered39
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare 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 $6,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number907128
Policy instance 4
Insurance contract or identification number907128
Number of Individuals Covered35
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare 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 $22,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC 0APB3
Policy instance 3
Insurance contract or identification numberGUC 0APB3
Number of Individuals Covered11
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $479
Total amount of fees paid to insurance companyUSD $194
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 BenefitYes
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 $3,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $479
Amount paid for insurance broker fees194
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A, 65970A
Policy instance 1
Insurance contract or identification numberN2910A, 65970A
Number of Individuals Covered8
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $14,199
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare 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 $228,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,199
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0APB3
Policy instance 8
Insurance contract or identification numberGVTL0APB3
Number of Individuals Covered28
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $3,312
Total amount of fees paid to insurance companyUSD $1,340
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY ACCIDENTAL 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 $22,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,312
Amount paid for insurance broker fees1340
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC 0APB3
Policy instance 3
Insurance contract or identification numberGUC 0APB3
Number of Individuals Covered13
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $528
Total amount of fees paid to insurance companyUSD $215
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 BenefitYes
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 $3,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $528
Amount paid for insurance broker fees215
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A, 65970A
Policy instance 1
Insurance contract or identification numberN2910A, 65970A
Number of Individuals Covered9
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $16,524
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare 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 $206,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,524
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 2
Insurance contract or identification number180063
Number of Individuals Covered81
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $44,500
Total amount of fees paid to insurance companyUSD $792
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 $888,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,500
Amount paid for insurance broker fees792
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number907128
Policy instance 4
Insurance contract or identification number907128
Number of Individuals Covered31
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $1,579
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,579
Insurance broker organization code?3
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number907128
Policy instance 5
Insurance contract or identification number907128
Number of Individuals Covered42
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $564
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $564
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0APB3
Policy instance 6
Insurance contract or identification numberGLUG0APB3
Number of Individuals Covered119
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $8,469
Total amount of fees paid to insurance companyUSD $2,236
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 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 $41,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,469
Amount paid for insurance broker fees2236
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0APB3
Policy instance 7
Insurance contract or identification numberGLTD0APB3
Number of Individuals Covered118
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $3,230
Total amount of fees paid to insurance companyUSD $1,302
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 $21,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,230
Amount paid for insurance broker fees1302
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0APB3
Policy instance 8
Insurance contract or identification numberGVTL0APB3
Number of Individuals Covered30
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $3,032
Total amount of fees paid to insurance companyUSD $1,205
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY ACCIDENTAL 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 $20,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,032
Amount paid for insurance broker fees1205
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A, 65970A
Policy instance 1
Insurance contract or identification numberN2910A, 65970A
Number of Individuals Covered13
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $23,670
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare 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 $295,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,670
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 2
Insurance contract or identification number180063
Number of Individuals Covered96
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $48,882
Total amount of fees paid to insurance companyUSD $953
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 $752,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,882
Amount paid for insurance broker fees953
Additional information about fees paid to insurance brokerBONUS AND NON-MONETARY COMPENSATION
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number907128-000, 099
Policy instance 3
Insurance contract or identification number907128-000, 099
Number of Individuals Covered39
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $2,602
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,602
Insurance broker organization code?3
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number907128-001, 199
Policy instance 4
Insurance contract or identification number907128-001, 199
Number of Individuals Covered51
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $885
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $9,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $885
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0APB3
Policy instance 5
Insurance contract or identification numberGLUG0APB3
Number of Individuals Covered133
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $8,405
Total amount of fees paid to insurance companyUSD $3,118
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 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 $40,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,405
Amount paid for insurance broker fees1871
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0APB3
Policy instance 6
Insurance contract or identification numberGLTD0APB3
Number of Individuals Covered133
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $3,441
Total amount of fees paid to insurance companyUSD $1,727
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 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 $22,942
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,441
Amount paid for insurance broker fees1036
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC 0APB3
Policy instance 7
Insurance contract or identification numberGUC 0APB3
Number of Individuals Covered15
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $588
Total amount of fees paid to insurance companyUSD $290
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 BenefitYes
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 $3,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $588
Amount paid for insurance broker fees174
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0APB3
Policy instance 8
Insurance contract or identification numberGVTL0APB3
Number of Individuals Covered32
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $3,062
Total amount of fees paid to insurance companyUSD $1,525
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY ACCIDENTAL 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 $20,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,062
Amount paid for insurance broker fees915
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 2
Insurance contract or identification number180063
Number of Individuals Covered110
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $39,791
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $725,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,791
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number907128-000, 099
Policy instance 3
Insurance contract or identification number907128-000, 099
Number of Individuals Covered28
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $2,575
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $25,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,575
Insurance broker organization code?3
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number907128-001, 199
Policy instance 4
Insurance contract or identification number907128-001, 199
Number of Individuals Covered41
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $1,016
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,016
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0APB3
Policy instance 5
Insurance contract or identification numberGLUG0APB3
Number of Individuals Covered151
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $8,452
Total amount of fees paid to insurance companyUSD $2,667
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 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 $41,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,452
Amount paid for insurance broker fees1436
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0APB3
Policy instance 6
Insurance contract or identification numberGLTD0APB3
Number of Individuals Covered140
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $3,264
Total amount of fees paid to insurance companyUSD $1,456
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 $21,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,264
Amount paid for insurance broker fees784
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC 0APB3
Policy instance 7
Insurance contract or identification numberGUC 0APB3
Number of Individuals Covered17
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $509
Total amount of fees paid to insurance companyUSD $216
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 BenefitYes
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 $3,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $509
Amount paid for insurance broker fees116
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A, 65970A
Policy instance 1
Insurance contract or identification numberN2910A, 65970A
Number of Individuals Covered13
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $21,050
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare 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 $263,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,050
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0APB3
Policy instance 8
Insurance contract or identification numberGVTL0APB3
Number of Individuals Covered34
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $2,937
Total amount of fees paid to insurance companyUSD $1,280
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY ACCIDENTAL 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 $19,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,937
Amount paid for insurance broker fees689
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0APB3
Policy instance 8
Insurance contract or identification numberGVTL0APB3
Number of Individuals Covered42
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $3,318
Total amount of fees paid to insurance companyUSD $1,950
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY ACCIDENTAL 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 $22,119
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,318
Amount paid for insurance broker fees1307
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A, 65970A
Policy instance 1
Insurance contract or identification numberN2910A, 65970A
Number of Individuals Covered14
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $19,987
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare 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 $249,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,987
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 2
Insurance contract or identification number180063
Number of Individuals Covered136
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $44,735
Total amount of fees paid to insurance companyUSD $1,733
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 $813,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,735
Amount paid for insurance broker fees1733
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number907128-000, 099
Policy instance 3
Insurance contract or identification number907128-000, 099
Number of Individuals Covered32
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $2,542
Total amount of fees paid to insurance companyUSD $128
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 $23,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,542
Amount paid for insurance broker fees128
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number907128-001, 199
Policy instance 4
Insurance contract or identification number907128-001, 199
Number of Individuals Covered61
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $1,303
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 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 $12,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,303
Amount paid for insurance broker fees62
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0APB3
Policy instance 5
Insurance contract or identification numberGLUG0APB3
Number of Individuals Covered165
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $9,525
Total amount of fees paid to insurance companyUSD $4,210
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 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 $46,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,525
Amount paid for insurance broker fees2807
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0APB3
Policy instance 6
Insurance contract or identification numberGLTD0APB3
Number of Individuals Covered162
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $4,543
Total amount of fees paid to insurance companyUSD $2,692
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 $30,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,543
Amount paid for insurance broker fees1812
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC 0APB3
Policy instance 7
Insurance contract or identification numberGUC 0APB3
Number of Individuals Covered17
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $544
Total amount of fees paid to insurance companyUSD $337
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 BenefitYes
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 $3,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $544
Amount paid for insurance broker fees223
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A, 65970A
Policy instance 1
Insurance contract or identification numberN2910A, 65970A
Number of Individuals Covered16
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $19,572
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 $244,653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,572
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 2
Insurance contract or identification number180063
Number of Individuals Covered139
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $47,507
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 $792,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,507
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number907128-000, 099
Policy instance 3
Insurance contract or identification number907128-000, 099
Number of Individuals Covered38
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $2,493
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 $23,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,493
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0APB3
Policy instance 5
Insurance contract or identification numberGLUG0APB3
Number of Individuals Covered178
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $9,161
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits 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 $44,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,161
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0APB3
Policy instance 6
Insurance contract or identification numberGLTD0APB3
Number of Individuals Covered171
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $4,560
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 $30,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,560
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0APB3
Policy instance 7
Insurance contract or identification numberGUC0APB3
Number of Individuals Covered21
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $634
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
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 $4,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $634
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0APB3
Policy instance 8
Insurance contract or identification numberGVTL0APB3
Number of Individuals Covered47
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $3,099
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY ACCIDENTAL 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 $20,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,099
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number907128-001, 199
Policy instance 4
Insurance contract or identification number907128-001, 199
Number of Individuals Covered68
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $1,419
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 $13,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,419
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0APB3
Policy instance 5
Insurance contract or identification numberGLTD0APB3
Number of Individuals Covered197
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $4,367
Total amount of fees paid to insurance companyUSD $913
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 $29,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,367
Amount paid for insurance broker fees913
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 1
Insurance contract or identification number180063
Number of Individuals Covered156
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $51,351
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 $850,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,351
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A, 65970A
Policy instance 2
Insurance contract or identification numberN2910A, 65970A
Number of Individuals Covered17
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $17,653
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 $220,664
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,653
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0APB3
Policy instance 3
Insurance contract or identification numberGLUG0APB3
Number of Individuals Covered209
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $6,590
Total amount of fees paid to insurance companyUSD $1,384
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits 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 $43,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,590
Amount paid for insurance broker fees1384
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0APB3
Policy instance 4
Insurance contract or identification numberGVTL0APB3
Number of Individuals Covered48
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $2,905
Total amount of fees paid to insurance companyUSD $618
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY ACCIDENTAL 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 $19,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,905
Amount paid for insurance broker fees618
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0APB3
Policy instance 6
Insurance contract or identification numberGUC0APB3
Number of Individuals Covered29
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $739
Total amount of fees paid to insurance companyUSD $159
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
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 $4,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $739
Amount paid for insurance broker fees159
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number907128-000, 099
Policy instance 7
Insurance contract or identification number907128-000, 099
Number of Individuals Covered27
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $2,170
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 $21,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,170
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 2
Insurance contract or identification number180063
Number of Individuals Covered153
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $47,494
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 $791,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,494
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A,65970A
Policy instance 1
Insurance contract or identification numberN2910A,65970A
Number of Individuals Covered17
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $15,677
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 $212,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,677
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 2
Insurance contract or identification number180063
Number of Individuals Covered152
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $47,498
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 $792,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,498
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A,65970A
Policy instance 1
Insurance contract or identification numberN2910A,65970A
Number of Individuals Covered20
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $18,816
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 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 $235,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,816
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 2
Insurance contract or identification number180063
Number of Individuals Covered159
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $48,822
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 $736,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A,65970A
Policy instance 1
Insurance contract or identification numberN2910A,65970A
Number of Individuals Covered5
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $18,644
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 $233,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN2910A,65970A
Policy instance 1
Insurance contract or identification numberN2910A,65970A
Number of Individuals Covered19
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $15,362
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 $192,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,362
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number180063
Policy instance 2
Insurance contract or identification number180063
Number of Individuals Covered151
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $34,500
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 $610,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,500
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameBOLTON & COMPANY

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