GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 401k Plan overview

Plan Name	GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP
Plan identification number	501

GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP Benefits

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

401k Sponsoring company profile

GOLDEN STATE FOODS CORP has sponsored the creation of one or more 401k plans.

Company Name:	GOLDEN STATE FOODS CORP
Employer identification number (EIN):	952670074
NAIC Classification:	311900
NAIC Description:	Other Food Manufacturing

Additional information about GOLDEN STATE FOODS CORP

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2006-07-03
Company Identification Number:	0800677100
Legal Registered Office Address:	18301 VON KARMAN AVE STE 1100 IRVINE United States of America (USA) 92612

More information about GOLDEN STATE FOODS CORP

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-02-01	ED RODRIGUEZ	2023-08-15
501	2021-02-01	ED RODRIGUEZ	2022-08-12
501	2020-02-01	PRAGNA PATEL	2021-08-30
501	2019-02-01	PRAGNA PATEL	2020-08-28
501	2018-02-01	PRAGNA PATEL	2019-08-22
501	2017-02-01
501	2016-02-01	JOHN D. MURPHY
501	2015-02-01	JOHN D MURPHY
501	2014-02-01	JOHN MURPHY
501	2013-02-01	JOHN D MURPHY
501	2012-02-01	JOHN D MURPHY		JOHN D MURPHY	2013-08-29
501	2011-02-01	JOHN D. MURPHY
501	2009-02-01	JOHN MURPHY

Plan Statistics for GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP

401k plan membership statisitcs for GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP

Measure	Date	Value
2022: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2022 401k membership
Total participants, beginning-of-year	2022-02-01	6,828
Total number of active participants reported on line 7a of the Form 5500	2022-02-01	4,480
Number of retired or separated participants receiving benefits	2022-02-01	43
Number of other retired or separated participants entitled to future benefits	2022-02-01	156
Total of all active and inactive participants	2022-02-01	4,679
Number of employers contributing to the scheme	2022-02-01	0
2021: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2021 401k membership
Total participants, beginning-of-year	2021-02-01	6,417
Total number of active participants reported on line 7a of the Form 5500	2021-02-01	3,894
Number of retired or separated participants receiving benefits	2021-02-01	57
Number of other retired or separated participants entitled to future benefits	2021-02-01	164
Total of all active and inactive participants	2021-02-01	4,115
Number of employers contributing to the scheme	2021-02-01	0
2020: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2020 401k membership
Total participants, beginning-of-year	2020-02-01	5,040
Total number of active participants reported on line 7a of the Form 5500	2020-02-01	3,250
Number of retired or separated participants receiving benefits	2020-02-01	5
Number of other retired or separated participants entitled to future benefits	2020-02-01	5
Total of all active and inactive participants	2020-02-01	3,260
Number of employers contributing to the scheme	2020-02-01	0
2019: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2019 401k membership
Total participants, beginning-of-year	2019-02-01	5,827
Total number of active participants reported on line 7a of the Form 5500	2019-02-01	4,241
Number of retired or separated participants receiving benefits	2019-02-01	0
Number of other retired or separated participants entitled to future benefits	2019-02-01	0
Total of all active and inactive participants	2019-02-01	4,241
Number of employers contributing to the scheme	2019-02-01	0
2018: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2018 401k membership
Total participants, beginning-of-year	2018-02-01	3,724
Total number of active participants reported on line 7a of the Form 5500	2018-02-01	4,595
Number of retired or separated participants receiving benefits	2018-02-01	21
Number of other retired or separated participants entitled to future benefits	2018-02-01	1,211
Total of all active and inactive participants	2018-02-01	5,827
Number of employers contributing to the scheme	2018-02-01	0
2017: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2017 401k membership
Total participants, beginning-of-year	2017-02-01	3,162
Total number of active participants reported on line 7a of the Form 5500	2017-02-01	3,484
Number of retired or separated participants receiving benefits	2017-02-01	23
Number of other retired or separated participants entitled to future benefits	2017-02-01	217
Total of all active and inactive participants	2017-02-01	3,724
2016: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2016 401k membership
Total participants, beginning-of-year	2016-02-01	2,791
Total number of active participants reported on line 7a of the Form 5500	2016-02-01	3,111
Number of retired or separated participants receiving benefits	2016-02-01	16
Number of other retired or separated participants entitled to future benefits	2016-02-01	35
Total of all active and inactive participants	2016-02-01	3,162
2015: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2015 401k membership
Total participants, beginning-of-year	2015-02-01	2,556
Total number of active participants reported on line 7a of the Form 5500	2015-02-01	2,722
Number of retired or separated participants receiving benefits	2015-02-01	16
Number of other retired or separated participants entitled to future benefits	2015-02-01	53
Total of all active and inactive participants	2015-02-01	2,791
2014: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2014 401k membership
Total participants, beginning-of-year	2014-02-01	2,303
Total number of active participants reported on line 7a of the Form 5500	2014-02-01	2,493
Number of retired or separated participants receiving benefits	2014-02-01	15
Number of other retired or separated participants entitled to future benefits	2014-02-01	48
Total of all active and inactive participants	2014-02-01	2,556
2013: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2013 401k membership
Total participants, beginning-of-year	2013-02-01	2,376
Total number of active participants reported on line 7a of the Form 5500	2013-02-01	2,295
Number of retired or separated participants receiving benefits	2013-02-01	8
Number of other retired or separated participants entitled to future benefits	2013-02-01	0
Total of all active and inactive participants	2013-02-01	2,303
2012: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2012 401k membership
Total participants, beginning-of-year	2012-02-01	2,364
Total number of active participants reported on line 7a of the Form 5500	2012-02-01	2,337
Number of retired or separated participants receiving benefits	2012-02-01	20
Number of other retired or separated participants entitled to future benefits	2012-02-01	19
Total of all active and inactive participants	2012-02-01	2,376
2011: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2011 401k membership
Total participants, beginning-of-year	2011-02-01	2,206
Total number of active participants reported on line 7a of the Form 5500	2011-02-01	2,316
Number of retired or separated participants receiving benefits	2011-02-01	8
Number of other retired or separated participants entitled to future benefits	2011-02-01	40
Total of all active and inactive participants	2011-02-01	2,364
2009: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2009 401k membership
Total participants, beginning-of-year	2009-02-01	1,476
Total number of active participants reported on line 7a of the Form 5500	2009-02-01	1,606
Number of retired or separated participants receiving benefits	2009-02-01	23
Number of other retired or separated participants entitled to future benefits	2009-02-01	0
Total of all active and inactive participants	2009-02-01	1,629
Total participants	2009-02-01	1,629

Form 5500 Responses for GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP

2022: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2022 form 5500 responses
2022-02-01	Type of plan entity	Single employer plan
2022-02-01	Plan funding arrangement – Insurance	Yes
2022-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-02-01	Plan benefit arrangement – Insurance	Yes
2022-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2021 form 5500 responses
2021-02-01	Type of plan entity	Single employer plan
2021-02-01	Plan funding arrangement – Insurance	Yes
2021-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-02-01	Plan benefit arrangement – Insurance	Yes
2021-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2020 form 5500 responses
2020-02-01	Type of plan entity	Single employer plan
2020-02-01	Plan funding arrangement – Insurance	Yes
2020-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-02-01	Plan benefit arrangement – Insurance	Yes
2020-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2019 form 5500 responses
2019-02-01	Type of plan entity	Single employer plan
2019-02-01	Plan funding arrangement – Insurance	Yes
2019-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-02-01	Plan benefit arrangement – Insurance	Yes
2019-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2018 form 5500 responses
2018-02-01	Type of plan entity	Single employer plan
2018-02-01	Plan funding arrangement – Insurance	Yes
2018-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-02-01	Plan benefit arrangement – Insurance	Yes
2018-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2017 form 5500 responses
2017-02-01	Type of plan entity	Single employer plan
2017-02-01	Plan funding arrangement – Insurance	Yes
2017-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-02-01	Plan benefit arrangement – Insurance	Yes
2017-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2016 form 5500 responses
2016-02-01	Type of plan entity	Single employer plan
2016-02-01	Submission has been amended	No
2016-02-01	This submission is the final filing	No
2016-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-02-01	Plan is a collectively bargained plan	No
2016-02-01	Plan funding arrangement – Insurance	Yes
2016-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-02-01	Plan benefit arrangement – Insurance	Yes
2016-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2015 form 5500 responses
2015-02-01	Type of plan entity	Single employer plan
2015-02-01	Submission has been amended	No
2015-02-01	This submission is the final filing	No
2015-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-02-01	Plan is a collectively bargained plan	No
2015-02-01	Plan funding arrangement – Insurance	Yes
2015-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-02-01	Plan benefit arrangement – Insurance	Yes
2015-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2014 form 5500 responses
2014-02-01	Type of plan entity	Single employer plan
2014-02-01	Submission has been amended	No
2014-02-01	This submission is the final filing	No
2014-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-02-01	Plan is a collectively bargained plan	No
2014-02-01	Plan funding arrangement – Insurance	Yes
2014-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-02-01	Plan benefit arrangement – Insurance	Yes
2014-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2013 form 5500 responses
2013-02-01	Type of plan entity	Single employer plan
2013-02-01	Submission has been amended	No
2013-02-01	This submission is the final filing	No
2013-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-02-01	Plan is a collectively bargained plan	No
2013-02-01	Plan funding arrangement – Insurance	Yes
2013-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-02-01	Plan benefit arrangement – Insurance	Yes
2013-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2012 form 5500 responses
2012-02-01	Type of plan entity	Single employer plan
2012-02-01	Submission has been amended	No
2012-02-01	This submission is the final filing	No
2012-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-02-01	Plan is a collectively bargained plan	No
2012-02-01	Plan funding arrangement – Insurance	Yes
2012-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-02-01	Plan benefit arrangement – Insurance	Yes
2012-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2011 form 5500 responses
2011-02-01	Type of plan entity	Single employer plan
2011-02-01	Submission has been amended	No
2011-02-01	This submission is the final filing	No
2011-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-02-01	Plan is a collectively bargained plan	No
2011-02-01	Plan funding arrangement – Insurance	Yes
2011-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-02-01	Plan benefit arrangement – Insurance	Yes
2011-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: GROUP INSURANCE PLAN FOR EMPLOYEES OF GOLDEN STATE FOODS CORP 2009 form 5500 responses
2009-02-01	Type of plan entity	Single employer plan
2009-02-01	Submission has been amended	No
2009-02-01	This submission is the final filing	No
2009-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-02-01	Plan is a collectively bargained plan	No
2009-02-01	Plan funding arrangement – Insurance	Yes
2009-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-02-01	Plan benefit arrangement – Insurance	Yes
2009-02-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )
Policy contract number	97253-001
Policy instance	3
Insurance contract or identification number 97253-001 Number of Individuals Covered 53 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $353,407 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	SA3890LF018001
Policy instance	7
Insurance contract or identification number SA3890LF018001 Number of Individuals Covered 4494 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $2,436,389 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	156264
Policy instance	6
Insurance contract or identification number 156264 Number of Individuals Covered 8 Insurance policy start date 2021-12-01 Insurance policy end date 2022-11-30 Total amount of commissions paid to insurance broker USD $7,484 Total amount of fees paid to insurance company USD $333 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $74,697 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,484 Amount paid for insurance broker fees 333 Additional information about fees paid to insurance broker PPP 3Q21 BONUS, PPP 4Q21 BONUS Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	5
Insurance contract or identification number ABL627989 Number of Individuals Covered 4766 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $128 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $8,643 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 128 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 )
Policy contract number	10038
Policy instance	4
Insurance contract or identification number 10038 Number of Individuals Covered 425 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,846,449 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	2
Insurance contract or identification number 12011932 Number of Individuals Covered 3378 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $472,034 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231181
Policy instance	1
Insurance contract or identification number 231181 Number of Individuals Covered 701 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,822,468 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	2
Insurance contract or identification number 12011932 Number of Individuals Covered 3335 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $478,940 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231181
Policy instance	1
Insurance contract or identification number 231181 Number of Individuals Covered 691 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $3,341 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,147,612 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 3341 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	SA3890LF018001
Policy instance	7
Insurance contract or identification number SA3890LF018001 Number of Individuals Covered 4213 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $29,458 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $2,416,638 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 29458 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )
Policy contract number	97253-001
Policy instance	3
Insurance contract or identification number 97253-001 Number of Individuals Covered 59 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $345,987 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 )
Policy contract number	10038
Policy instance	4
Insurance contract or identification number 10038 Number of Individuals Covered 492 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $500 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,933,437 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 500 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	5
Insurance contract or identification number ABL627989 Number of Individuals Covered 4766 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $106 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $8,643 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 106 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	156264-010-0002
Policy instance	6
Insurance contract or identification number 156264-010-0002 Number of Individuals Covered 8 Insurance policy start date 2020-12-01 Insurance policy end date 2021-11-30 Total amount of commissions paid to insurance broker USD $5,468 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $61,209 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $5,468 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	2
Insurance contract or identification number 12011932 Number of Individuals Covered 2930 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $435,917 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231181
Policy instance	1
Insurance contract or identification number 231181 Number of Individuals Covered 693 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $13,549 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,094,967 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 13549 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	97253-001
Policy instance	3
Insurance contract or identification number 97253-001 Number of Individuals Covered 57 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $312,325 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 )
Policy contract number	10038
Policy instance	4
Insurance contract or identification number 10038 Number of Individuals Covered 505 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,794,069 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	5
Insurance contract or identification number ABL627989 Number of Individuals Covered 3250 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $68 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $6,843 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 68 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	SA3890LF018001
Policy instance	7
Insurance contract or identification number SA3890LF018001 Number of Individuals Covered 3493 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $40,063 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $1,579,415 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 40063 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
AETNA GLOBAL BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	29908305200259
Policy instance	6
Insurance contract or identification number 29908305200259 Number of Individuals Covered 1 Insurance policy start date 2020-01-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $262 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $1,338 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $262 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231181
Policy instance	1
Insurance contract or identification number 231181 Number of Individuals Covered 772 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,837,586 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	150774
Policy instance	6
Insurance contract or identification number 150774 Number of Individuals Covered 2032 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $907,413 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	2
Insurance contract or identification number 12011932 Number of Individuals Covered 2435 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $363,374 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number	120887
Policy instance	3
Insurance contract or identification number 120887 Number of Individuals Covered 4241 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $474,504 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	97253-1/97253-3
Policy instance	4
Insurance contract or identification number 97253-1/97253-3 Number of Individuals Covered 58 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $312,975 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	7
Insurance contract or identification number ABL627989 Number of Individuals Covered 4241 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $56 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $6,843 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 56 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	29908305200259
Policy instance	8
Insurance contract or identification number 29908305200259 Number of Individuals Covered 1 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $701 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $7,680 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $701 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	C19579
Policy instance	9
Insurance contract or identification number C19579 Number of Individuals Covered 4324 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $8,813 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $51,480 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,813 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 )
Policy contract number	10038
Policy instance	5
Insurance contract or identification number 10038 Number of Individuals Covered 508 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,840,624 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA GLOBAL BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	299083-052-0259
Policy instance	11
Insurance contract or identification number 299083-052-0259 Number of Individuals Covered 7 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $4,101 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $41,825 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,101 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	10
Insurance contract or identification number ABL627989 Number of Individuals Covered 0 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $136 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $6,710 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 136 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	GOLD01, GOLD02
Policy instance	8
Insurance contract or identification number GOLD01, GOLD02 Number of Individuals Covered 11854 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $80,167 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	10-032487
Policy instance	7
Insurance contract or identification number 10-032487 Number of Individuals Covered 125 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $30 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,467 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 30 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 )
Policy contract number	10038
Policy instance	6
Insurance contract or identification number 10038 Number of Individuals Covered 493 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,247,851 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	97253
Policy instance	5
Insurance contract or identification number 97253 Number of Individuals Covered 57 Insurance policy start date 2016-07-01 Insurance policy end date 2017-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $279,788 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number	120887
Policy instance	4
Insurance contract or identification number 120887 Number of Individuals Covered 3484 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $466,688 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MERCYCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60215 )
Policy contract number	501820
Policy instance	3
Insurance contract or identification number 501820 Number of Individuals Covered 293 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,813,534 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	2
Insurance contract or identification number 12011932 Number of Individuals Covered 3078 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231181
Policy instance	1
Insurance contract or identification number 231181 Number of Individuals Covered 860 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $1,054 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,472,240 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 1054 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	150774
Policy instance	9
Insurance contract or identification number 150774 Number of Individuals Covered 2207 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,027,147 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	GOLD01/GOLD02
Policy instance	11
Insurance contract or identification number GOLD01/GOLD02 Number of Individuals Covered 6543 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $63,154 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MERCYCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60215 )
Policy contract number	501820
Policy instance	4
Insurance contract or identification number 501820 Number of Individuals Covered 296 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,369,354 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231181
Policy instance	1
Insurance contract or identification number 231181 Number of Individuals Covered 712 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,090,355 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 )
Policy contract number	10038
Policy instance	2
Insurance contract or identification number 10038 Number of Individuals Covered 578 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,085,541 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	97253
Policy instance	3
Insurance contract or identification number 97253 Number of Individuals Covered 68 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $266,808 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	10
Insurance contract or identification number ABL627989 Number of Individuals Covered 2722 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $67 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,710 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Amount paid for insurance broker fees 67 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	150774
Policy instance	9
Insurance contract or identification number 150774 Number of Individuals Covered 1759 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $674,026 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number	120887
Policy instance	8
Insurance contract or identification number 120887 Number of Individuals Covered 2722 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $353,412 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	7
Insurance contract or identification number 12011932 Number of Individuals Covered 3884 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA GLOBAL BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	299083-52-0259
Policy instance	5
Insurance contract or identification number 299083-52-0259 Number of Individuals Covered 9 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $6,118 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $59,772 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,118 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	010-032487
Policy instance	6
Insurance contract or identification number 010-032487 Number of Individuals Covered 127 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $16 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,031 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 16 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 )
Policy contract number	10038
Policy instance	3
Insurance contract or identification number 10038 Number of Individuals Covered 548 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $4,472 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,812,175 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,472 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231181
Policy instance	2
Insurance contract or identification number 231181 Number of Individuals Covered 591 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $32 Total amount of fees paid to insurance company USD $2,250 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,026,056 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32 Amount paid for insurance broker fees 2250 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	C19579
Policy instance	1
Insurance contract or identification number C19579 Number of Individuals Covered 4530 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $174,078 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,611,399 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $174,078 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	97253
Policy instance	4
Insurance contract or identification number 97253 Number of Individuals Covered 66 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $254,012 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MERCYCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60215 )
Policy contract number	501820
Policy instance	6
Insurance contract or identification number 501820 Number of Individuals Covered 288 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,260,313 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA GLOBAL BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	299083-52-0259
Policy instance	5
Insurance contract or identification number 299083-52-0259 Number of Individuals Covered 11 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $4,753 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $51,104 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,753 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number	120887
Policy instance	8
Insurance contract or identification number 120887 Number of Individuals Covered 2555 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $601,957 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	9
Insurance contract or identification number ABL627989 Number of Individuals Covered 2493 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $48 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,710 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Amount paid for insurance broker fees 48 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE, INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	150774
Policy instance	10
Insurance contract or identification number 150774 Number of Individuals Covered 1563 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $545,019 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	GOLD01/GOLD02
Policy instance	11
Insurance contract or identification number GOLD01/GOLD02 Number of Individuals Covered 5983 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $62,512 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	10-032487
Policy instance	12
Insurance contract or identification number 10-032487 Number of Individuals Covered 69 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $484 Total amount of fees paid to insurance company USD $1,133 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,480 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1133 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3 Commission paid to Insurance Broker USD $484 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	7
Insurance contract or identification number 12011932 Number of Individuals Covered 2124 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA GLOBAL BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	299083-52-259
Policy instance	5
Insurance contract or identification number 299083-52-259 Number of Individuals Covered 8 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $2,462 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $27,790 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,462 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	7
Insurance contract or identification number 12011932 Number of Individuals Covered 1660 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 )
Policy contract number	10038
Policy instance	3
Insurance contract or identification number 10038 Number of Individuals Covered 528 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $14,513 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,593,868 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,513 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231181
Policy instance	2
Insurance contract or identification number 231181 Number of Individuals Covered 515 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $17,905 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,787,924 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,905 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	C19579
Policy instance	1
Insurance contract or identification number C19579 Number of Individuals Covered 4020 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $180,453 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,061,931 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $180,453 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	97253
Policy instance	4
Insurance contract or identification number 97253 Number of Individuals Covered 67 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $215,014 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number	120887
Policy instance	8
Insurance contract or identification number 120887 Number of Individuals Covered 2295 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $260,909 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	150774
Policy instance	10
Insurance contract or identification number 150774 Number of Individuals Covered 1386 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $496,496 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	GOLD01/GOLD02
Policy instance	11
Insurance contract or identification number GOLD01/GOLD02 Number of Individuals Covered 5516 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $58,915 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	9
Insurance contract or identification number ABL627989 Number of Individuals Covered 3332 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $65 Total amount of fees paid to insurance company USD $48 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,417 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $65 Amount paid for insurance broker fees 48 Additional information about fees paid to insurance broker SUPPLEMENTAL COMMISSION Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	731412
Policy instance	12
Insurance contract or identification number 731412 Number of Individuals Covered 388 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $50,201 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,673,358 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,103 Insurance broker organization code? 3 Insurance broker name CLJM, LLC
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	10-032487
Policy instance	13
Insurance contract or identification number 10-032487 Number of Individuals Covered 323 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $2,399 Total amount of fees paid to insurance company USD $1,117 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $98,607 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,442 Insurance broker organization code? 3 Amount paid for insurance broker fees 1117 Additional information about fees paid to insurance broker FEES Insurance broker name CLJM, LLC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	484296
Policy instance	14
Insurance contract or identification number 484296 Number of Individuals Covered 145 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $4,133 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $41,328 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,223 Insurance broker organization code? 3 Insurance broker name CLJM,LLC
MERCYCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60215 )
Policy contract number	501820
Policy instance	6
Insurance contract or identification number 501820 Number of Individuals Covered 282 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $11,160 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,122,244 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,160 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	C19579
Policy instance	1
Insurance contract or identification number C19579 Number of Individuals Covered 2232 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $180,140 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $180,140 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 )
Policy contract number	10038
Policy instance	3
Insurance contract or identification number 10038 Number of Individuals Covered 571 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $15,795 Total amount of fees paid to insurance company USD $50,250 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,579,481 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,795 Amount paid for insurance broker fees 50250 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	97253
Policy instance	4
Insurance contract or identification number 97253 Number of Individuals Covered 59 Insurance policy start date 2011-07-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $216,754 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	299083-52-259
Policy instance	5
Insurance contract or identification number 299083-52-259 Number of Individuals Covered 6 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $1,265 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $23,160 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,265 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
MERCYCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60215 )
Policy contract number	501820
Policy instance	6
Insurance contract or identification number 501820 Number of Individuals Covered 268 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $10,381 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,038,102 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,381 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	7
Insurance contract or identification number 12011932 Number of Individuals Covered 1703 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	9
Insurance contract or identification number ABL627989 Number of Individuals Covered 2337 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $96 Total amount of fees paid to insurance company USD $32 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,417 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $96 Amount paid for insurance broker fees 32 Additional information about fees paid to insurance broker SUPPLEMENTAL COMMISSION Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	564131/584479
Policy instance	10
Insurance contract or identification number 564131/584479 Number of Individuals Covered 1178 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $618,916 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	GOLD01/GOLD02
Policy instance	11
Insurance contract or identification number GOLD01/GOLD02 Number of Individuals Covered 5614 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $59,627 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231181
Policy instance	2
Insurance contract or identification number 231181 Number of Individuals Covered 486 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $15,778 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,587,725 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,778 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number	120887
Policy instance	8
Insurance contract or identification number 120887 Number of Individuals Covered 2337 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $281,873 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	97253
Policy instance	4
Insurance contract or identification number 97253 Number of Individuals Covered 64 Insurance policy start date 2011-01-01 Insurance policy end date 2011-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $108,225 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number	1005829000
Policy instance	2
Insurance contract or identification number 1005829000 Number of Individuals Covered 598 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $31,982 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,066,821 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	1005829000
Policy instance	3
Insurance contract or identification number 1005829000 Number of Individuals Covered 417 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $21,516 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,390,423 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	GOLD0-001
Policy instance	12
Insurance contract or identification number GOLD0-001 Number of Individuals Covered 4982 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $57,377 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )
Policy contract number	X0181
Policy instance	10
Insurance contract or identification number X0181 Number of Individuals Covered 58 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $697,068 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	9
Insurance contract or identification number ABL627989 Number of Individuals Covered 2251 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $32 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,417 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number	120887
Policy instance	8
Insurance contract or identification number 120887 Number of Individuals Covered 2251 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $282,376 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	7
Insurance contract or identification number 12011932 Number of Individuals Covered 1467 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number	1925
Policy instance	6
Insurance contract or identification number 1925 Number of Individuals Covered 60 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $1,562 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA GLOBAL BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	299083-52-259
Policy instance	5
Insurance contract or identification number 299083-52-259 Number of Individuals Covered 9 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $4,033 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $37,887 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	C19579
Policy instance	1
Insurance contract or identification number C19579 Number of Individuals Covered 3995 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $181,404 Total amount of fees paid to insurance company USD $166 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,154,625 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	564131
Policy instance	11
Insurance contract or identification number 564131 Number of Individuals Covered 1238 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $523,810 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	564131
Policy instance	13
Insurance contract or identification number 564131 Number of Individuals Covered 69 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,193 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12011932
Policy instance	2
Insurance contract or identification number 12011932 Number of Individuals Covered 1319 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )
Policy contract number	X0181
Policy instance	3
Insurance contract or identification number X0181 Number of Individuals Covered 47 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $522,697 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	GOLD0-001, 002
Policy instance	4
Insurance contract or identification number GOLD0-001, 002 Number of Individuals Covered 2190 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $48,872 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number	1925
Policy instance	5
Insurance contract or identification number 1925 Number of Individuals Covered 141 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA GLOBAL BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	299083-52-259
Policy instance	7
Insurance contract or identification number 299083-52-259 Number of Individuals Covered 9 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $2,079 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $30,580 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,079 Insurance broker organization code? 3 Insurance broker name AON CONSULTING
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )
Policy contract number	584524
Policy instance	8
Insurance contract or identification number 584524 Number of Individuals Covered 76 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,139 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	C19579
Policy instance	6
Insurance contract or identification number C19579 Number of Individuals Covered 3369 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $162,971 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $812,479 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $143,779 Insurance broker organization code? 3 Insurance broker name BENEFITS AND RISK SOLUTIONS, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	584479
Policy instance	10
Insurance contract or identification number 584479 Number of Individuals Covered 1055 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $462,938 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	1005829000
Policy instance	9
Insurance contract or identification number 1005829000 Number of Individuals Covered 404 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $33,556 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,045,559 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,556 Insurance broker organization code? 3 Insurance broker name AON CONSULTING
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	97253
Policy instance	11
Insurance contract or identification number 97253 Number of Individuals Covered 25 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $203,526 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	ABL627989
Policy instance	12
Insurance contract or identification number ABL627989 Number of Individuals Covered 2216 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $4,833 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number	120887
Policy instance	1
Insurance contract or identification number 120887 Number of Individuals Covered 2191 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $238,708 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No

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• GROUP INSURANCE & HEALTH BENEFITS FOR SALARIED CORPORATE PERSONNEL [EIN = 131673581]
• GROUP INSURANCE PLAN VIKING PUMP HOURLY EMPLOYEES LOCAL 459 [EIN = 133372066]
• GROUP INSURANCE PLAN FOR CERTAIN RETIREES OF ANHEUSER-BUSCH COMPANIES, LLC AND ITS SUBSIDIARIES [EIN = 431162835]
• GROUP INSURANCE PLAN FOR BARGAINING UNIT EMPLOYEES [EIN = 232617050]
• GROUP INSURANCE [EIN = 041663150]
• GROUP INSURANCE FOR EMPLOYEES OF DEGOLYER & MACNAUGHTON [EIN = 750771709]
• GROUP INSURANCE MEDICAL DENTAL PLAN [EIN = 951958272]
• GROUP INSURANCE PLAN FOR MURPHY OIL CORPORATION [EIN = 710361522]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF USPA [EIN = 751054341]
• GROUP INSURANCE PLAN [EIN = 420662937]
• GROUP INSURANCE PLAN [EIN = 931074455]
• GROUP INSURANCE PLAN FOR PETROLIA HOURLY EMPLOYEES [EIN = 251720937]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF HENRY VISCARDI SCHOOL [EIN = 112024514]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF JACKSON ELECTRIC MEMBERSHIP CORPORATION [EIN = 580301471]
• GROUP INSURANCE PLAN FOR HARNISH GROUP INC. [EIN = 911978007]
• GROUP INSURANCE PLAN HOURLY AND SALARIED EMPLOYEES OF PARKER HANNIFIN CORP [EIN = 340451060]
• GROUP INSURANCE FOR EMPLOYEES OF OHIO GAS COMPANY [EIN = 344320120]
• GROUP INSURANCE PLAN [EIN = 340863886]
• GROUP INSURANCE PLAN FOR EMPLOYEES [EIN = 590630270]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF THE AMERICAN CIVIL LIBERTIES UNION, INC. [EIN = 133871360]
• GROUP INSURANCE PLAN OF ASHWORTH BROS., INC. [EIN = 320002391]
• GROUP INSURANCE FOR EMPLOYEES OF HACKENSACK UNIVERSITY MEDICAL CENTER [EIN = 221487576]
• GROUP INSURANCE PLANS [EIN = 134924125]
• GROUP INSURANCE PLAN CLARK MICHIGAN COMPANY RETIRED SALARY EMPLOYEES [EIN = 382496821]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF MAGNESITA REFRACTORIES COMPANY [EIN = 230380777]
• GROUP INSURANCE PLAN [EIN = 113523578]
• GROUP INSURANCE PLAN TRAVEL ACCIDENT INSURANCE PLAN [EIN = 371225456]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF SPRINGFIELD CLINIC [EIN = 370701328]
• GROUP INSURANCE ASSOCIATES 401 K PROFIT SHARING PLAN TRUST [EIN = 061423803]
• GROUP INSURANCE [EIN = 510070531]
• GROUP INSURANCE SOLUTIONS, INC. 401K PLAN [EIN = 043448161]
• GROUP INSURANCE SERVICE CENTER, INC 401(K) PROFIT SHARING PLAN [EIN = 043271304]
• GROUP INSURANCE PLANNERS, INC. PROFIT SHARING PLAN [EIN = 521089829]
• GROUP INSURANCE TRUST OF THE CALIFORNIA SOCIETY OF CERTIFIED PUBLIC ACCOUNTANTS 401K [EIN = 942767563]
• GROUP INSURANCE PROGRAM FOR HOURLY EMPLOYEES IN NEWPORT, ARKANSAS [EIN = 310946477]
• GROUP INSURANCE PROGRAM [EIN = 370602744]
• GROUP INSURANCE PLAN, CATERPILLAR, INC. [EIN = 370602744]
• GROUP INSURANCE PLAN AD&D [EIN = 261974324]
• GROUP INSURANCE PLAN [EIN = 251799439]
• GROUP INSURANCE PLAN [EIN = 410954702]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF AMPAL INC [EIN = 221840978]
• GROUP INSURANCE PLAN FOR C.H. GUENTHER & SON, INC [EIN = 741508677]
• GROUP INSURANCE PLAN OF ACCURIDE INTL INC & ASSOCIATED COMPANIES [EIN = 952462461]
• GROUP INSURANCE PLAN FOR ACTIVE AND RETIRED EMPLOYEES OF BERRY COLLEGE [EIN = 580566133]
• GROUP INSURANCE PLAN FOR INTERNATIONAL FLAVORS & FRAGRANCES INC. [EIN = 131432060]
• GROUP INSURANCE PLAN FOR NON-SALARIED EMPLOYEES OF CIBA SPECIALTY CHEMICALS AT TOMS RIVER, NJ [EIN = 133904291]
• GROUP INSURANCE PROGRAM FOR EMPLOYEES OF OLEAN GENERAL HOSPITAL [EIN = 160743102]
• GROUP INSURANCE FOR EMPLOYEES OF GOODWILL INDUSTRIES [EIN = 560844639]
• GROUP INSURANCE PLAN FOR THE MEMBERS OF PROFESSION HOCKEY PLAYERS ASSOCIATION/AMERICAN HOCKEY LEAGUE [EIN = 911820950]
• GROUP INSURANCE FOR ASSOCIATES OF ATLAS INDUSTRIES [EIN = 344179243]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF NATIONS FOODSERVICE, INC. [EIN = 942311759]
• GROUP INSURANCE PLAN [EIN = 134978230]
• GROUP INSURANCE FOR THE EMPLOYEES OF WOODFOLD MFG INC [EIN = 930653578]
• GROUP INSURANCE AND HEALTH BENEFITS FOR HOURLY EMPLOYEES OF GENERAL DYNAMICS, SPACE SYSTEMS DIV. [EIN = 131673581]
• GROUP INSURANCE PLAN [EIN = 141543982]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF ALBEMARLE CORPORATION [EIN = 541692118]
• GROUP INSURANCE PLAN SALARIED [EIN = 133429953]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF SILVER SPRINGS CITRUS, INC. [EIN = 591149667]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF WAYTEC ELECTRONICS CORPORATION [EIN = 541425895]
• GROUP INSURANCE FOR HOULY WORKERS OF AY MCDONALD MFG CO [EIN = 420404280]
• GROUP INSURANCE PLAN [EIN = 060653264]
• GROUP INSURANCE PLAN [EIN = 132520327]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF WESTERN EXTERMINATOR COMPANY [EIN = 951716377]
• GROUP INSURANCE PL FOR BARGAINING EMPLOYEES OF UNION SWITCH [EIN = 250900465]
• GROUP INSURANCE PLAN OF ROSE HILLS [EIN = 133915765]
• GROUP INSURANCE PLAN FOR EMPLOYEES [EIN = 340562210]
• GROUP INSURANCE PLAN FOR HOURLY EMPLOYEES OF PAINTSVILLE PLANT [EIN = 250900465]
• GROUP INSURANCE PLAN OF SOUTHCO, INC. [EIN = 231287596]
• GROUP INSURANCE FOR THE EMPLOYEES OF GARAN INCORPORATED [EIN = 135665557]
• GROUP INSURANCE PLAN FOR LANE LIMITED [EIN = 200546644]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF BICKERSTAFF CLAY PRODUCTS COMPANY, INC. [EIN = 580349750]
• GROUP INSURANCE PLAN [EIN = 560117700]
• GROUP INSURANCE FOR EMPLOYEES OF LEADING TECHNOLOGIES, INC. [EIN = 510363266]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF TRINITY EPISCOPAL SCHOOL CORPORATION [EIN = 135563003]
• GROUP INSURANCE FOR EMPLOYEES OF OSG SHIP MANAGEMENT, INC. [EIN = 133589004]
• GROUP INSURANCE PLAN FOR HOURLY EMPLOYEES OF U.S. BRONZE [EIN = 221610152]
• GROUP INSURANCE PLAN HOME AIDES OF CENTRAL NEW YORK [EIN = 160916474]
• GROUP INSURANCE PLANS [EIN = 134978230]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF AETNA INC. [EIN = 232229683]
• GROUP INSURANCE PLANS OF THE COCA-COLA BOTTLERS' ASSOCIATION [EIN = 580198280]
• GROUP INSURANCE PLAN AND SECTION 125 [EIN = 592741848]
• GROUP INSURANCE PLAN, ALTERNATIVES UNLIMITED, INC. [EIN = 042587863]
• GROUP INSURANCE & HEALTH BENEFITS FOR SALARIED EMPLOYEES OF GENERAL DYNAMICS, AIR DEFENSE SYSTEMS, POMONA FACILITY [EIN = 131673581]
• GROUP INSURANCE PLAN [EIN = 930662669]
• GROUP INSURANCE PLAN [EIN = 371001726]
• GROUP INSURANCE PLAN [EIN = 481109486]
• GROUP INSURANCE BENEFITS FOR AIR WISCONSIN AIRLINES CORPORATION [EIN = 391767281]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF OFFSET PAPERBACK [EIN = 231873471]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF RUSSELECTRIC, INC. [EIN = 042278461]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF ISRAEL DISCOUNT BANK OF NEW YORK [EIN = 135596781]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF FSC II LLC [EIN = 562106089]
• GROUP INSURANCE PLAN OF MARKETING ASSOCIATES LLC [EIN = 383585841]
• GROUP INSURANCE PLAN OF HARVEY HUBBELL, INC. [EIN = 060397030]
• GROUP INSURANCE BENEFITS PLAN [EIN = 203906245]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF JAMESON HOSPITAL [EIN = 251536036]
• GROUP INSURANCE PLAN FOR RETIRED SALARIED EMPLOYEES OF HARLEY-DAVIDSON MOTOR GROUP, INC. [EIN = 391805420]
• GROUP INSURANCE & HEALTH BENEFITS FOR GENERAL DYNAMICS LAND SYSTEMS BARGAINING EMPLOYEES [EIN = 131673581]
• GROUP INSURANCE PLAN AD&D INSURANCE [EIN = 371225456]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF QC DATA LLC [EIN = 840848131]
• GROUP INSURANCE PLAN [EIN = 580190830]
• GROUP INSURANCE PLAN [EIN = 452015136]
• GROUP INSURANCE PLAN [EIN = 474779870]
• GROUP INSURANCE PLAN [EIN = 741554976]
• GROUP INSURANCE PLAN FOR RETIRED BARGAINING UNIT EMPLOYEES OF HARLEY DAVIDSON MOTOR COMPANY GROUP, INC. [EIN = 391805420]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF KNAPE AND VOGT MANUFACTURING COMPANY [EIN = 380722920]
• GROUP INSURANCE PLAN [EIN = 474779870]
• GROUP INSURANCE PLAN FOR RETAIL STORE MANAGERS OF MURPHY USA INC. [EIN = 462279221]
• GROUP INSURANCE PLAN UNDER THE AICPA GROUP INSURANCE TRUST [EIN = 456549619]
• GROUP INSURANCE PLAN FOR RETIREES OF THE WOOSTER BRUSH CO [EIN = 340628460]
• GROUP INSURANCE PLAN OF GENE B. GLICK COMPANY, INC. [EIN = 350924178]
• GROUP INSURANCE PLAN OF ELECTRO SWITCH CORP. [EIN = 042037902]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF POLAR CORP. [EIN = 043026575]
• GROUP INSURANCE TRUST (DELAWARE) - DREW MARINE GROUP, INC. [EIN = 270440420]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF I.L. LONG CONSTRUCTION COMPANY, INC. [EIN = 560860756]
• GROUP INSURANCE PLAN OF UNITED WAY OF ALLEN COUNTY, INC. [EIN = 350867932]
• GROUP INSURANCE PLAN OF KNEIBERT CLINIC [EIN = 430639459]
• GROUP INSURANCE PLAN FOR ASSOCIATES OF ATLAS INDUSTRIES, INC. [EIN = 344179243]
• GROUP INSURANCE PLAN UNITED MINE WORKERS [EIN = 592981186]
• GROUP INSURANCE FOR EMPLOYEES OF COMPOSIDIE, INC. [EIN = 251232176]
• GROUP INSURANCE FOR EMPLOYEES OF DIAGNOSTIC HYBRIDS, INC. [EIN = 311050325]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF RUBICON LLC [EIN = 720927730]
• GROUP INSURANCE BENEFITS FOR EMPLOYEES OF JAMES P. LINETTE, INC. [EIN = 581686770]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF NEC AND AFFILIATES [EIN = 200665337]
• GROUP INSURANCE PLAN [EIN = 371001725]
• GROUP INSURANCE PLAN FOR EMPLOYEES [EIN = 650019093]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF SUNSHINE RESTAURANT MERGE SUB, LLC [EIN = 208952385]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF J C EHRLICH CO., INC DBA WESTERN EXTERMINATOR COMPANY [EIN = 231568350]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF K&M MACHINE - FABRICATING, INC. [EIN = 382509038]
• GROUP INSURANCE AND WELFARE PLAN [EIN = 010113635]
• GROUP INSURANCE PLAN OF THE LOXCREEN COMPANY INC. [EIN = 731578428]
• GROUP INSURANCE PLAN [EIN = 431270780]
• GROUP INSURANCE PLAN UNDER THE AICPA INSURANCE TRUST [EIN = 136076154]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF DOW JONES LO [EIN = 141513238]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF LUTHERAN HOMES OF SC, INC. [EIN = 570327887]
• GROUP INSURANCE FOR SALARIED EMPLOYEES OF BLH DIVISION [EIN = 361169950]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF SABRELINER CORPORATION [EIN = 431289921]
• GROUP INSURANCE PLAN FOR SALARIED EMPLOYEES OF U.S. BRONZE [EIN = 221610152]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF CAROLINA FURNITURE WORKS INC [EIN = 570382139]
• GROUP INSURANCE PLAN OF MURPHY OIL USA, INC. [EIN = 710361522]
• GROUP INSURANCE PLAN FOR HOURLY EMPLOYEES OF U. S. ALUMINUM, INC. [EIN = 222766798]
• GROUP INSURANCE PLAN [EIN = 131432885]
• GROUP INSURANCE PLAN OF THE LOXCREEN COMPANY INC. [EIN = 570330702]
• GROUP INSURANCE PLAN FOR EMPLOYEES FORMERLY OF BASF CATALYSTS, LLC [EIN = 161090809]
• GROUP INSURANCE PLAN FOR HOURLY EMPLOYEES AT MCINTOSH, AL [EIN = 161090809]
• GROUP INSURANCE PLAN OF FAMILY HOME HEALTH SERVICES [EIN = 200164933]
• GROUP INSURANCE FOR HOURLY EMPLOYEES OF BLH DIVISION [EIN = 361169950]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF THE BILTRITE CORPORATION [EIN = 043031551]
• GROUP INSURANCE HOSPITAL PLAN [EIN = 591490411]
• GROUP INSURANCE PLAN FOR HOURLY EMPLOYEES OF CHINAWARE DIV [EIN = 250900465]
• GROUP INSURANCE PLAN FOR MOSES TAYLOR HOSPITAL [EIN = 240795461]
• GROUP INSURANCE PLAN [EIN = 470428274]
• GROUP INSURANCE PLAN FOR NON-SALARIED EMPLOYEES AT TOMS RIVER, NJ [EIN = 161090809]
• GROUP INSURANCE PLAN FOR EMPLOYEES AT SUPERIOR WI REFINERY [EIN = 364579817]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF NATIONAL FRICTION PRODUCTS [EIN = 251539808]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF THE COLLEGE OF WOOSTER [EIN = 340714654]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF THE AMERICAN CIVIL LIBERTIES UNION, INC. [EIN = 134921750]
• GROUP INSURANCE PLAN FOR HOURLY EMPLOYEES OF LOUISVILLE PLANT [EIN = 250900465]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF CHESEBROUGH-PONDS MANUFACTURING COMPANY [EIN = 060955014]
• GROUP INSURANCE PLAN OF SMURFIT-STONE CONT. CORP. AND ITS WHOLLY OWNED SUBSIDIARIES AND AFFILIATES [EIN = 362041256]
• GROUP INSURANCE FOR AMERICAN METALS CORPORATION VISION PLAN SERVICES [EIN = 680284528]
• GROUP INSURANCE FOR SALARIED EMPLOYEES OF CRUCIBLE INC.-STEEL PLAN [EIN = 133179229]
• GROUP INSURANCE PLAN [EIN = 520565065]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF MID-STATES RUBBER PRODUCTS, INC. [EIN = 350818191]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF SCHENKER, INC. [EIN = 135619239]
• GROUP INSURANCE ARRANGEMENT OF WELFARE PLANS [EIN = 465718220]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES AND RETIREES OF CHEYENNE LIGHT FUEL & POWER COMPANY [EIN = 460458824]
• GROUP INSURANCE FOR EMPLOYEES OF FUJIFILM MEDICAL SYSTEMS, USA, INC. [EIN = 132531985]
• GROUP INSURANCE PLAN FOR CONKLIN EMPLOYEES [EIN = 410754077]
• GROUP INSURANCE PROTECTION [EIN = 580813156]
• GROUP INSURANCE PLAN OF AMERICAN METALS CORPORATION [EIN = 680284528]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF ABILITIES, INC. [EIN = 111710419]
• GROUP INSURANCE PLAN FOR ELIGIBLE SALARIED EMPLOYEES OF RMI TITANIUM CO [EIN = 341913054]
• GROUP INSURANCE PLAN FOR EMPLOYEES [EIN = 590630270]
• GROUP INSURANCE FOR OTHER EMPLOYEES OF AY MCDONALD MFG CO [EIN = 421241542]
• GROUP INSURANCE PLAN [EIN = 131548339]
• GROUP INSURANCE LIFE PLAN [EIN = 911959949]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF JOSEPH DECOSIMO AND COMPANY, PLLC [EIN = 620852719]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF MIDLANTIC MACHINERY COMPANY [EIN = 134334615]
• GROUP INSURANCE PLAN AD&D [EIN = 911959949]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF IPEX, USA LLC [EIN = 561188786]
• GROUP INSURANCE FOR EMPLOYEES OF ROYAL OAK ENTERPRISES, INC. [EIN = 582498652]
• GROUP INSURANCE PLAN OF CRAFTMASTER FURNITURE, INC [EIN = 204595928]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF CIBA SPECIALTY CHEMICALS CORPORATION [EIN = 133904291]
• GROUP INSURANCE PLAN FOR THE EMPLOYEES OF K&M MACHINE - FABRICATING, INC. [EIN = 381443609]
• GROUP INSURANCE PLAN FOR EMPLOYEES AT SUPERIOR WI REFINERY [EIN = 710361522]
• GROUP INSURANCE PLAN RTI ALLOYS DIVISION CO RTI ALLOYS DIVISION [EIN = 341913054]
• GROUP INSURANCE PLAN OF THACHER PROFFITT & WOOD LLP [EIN = 135612353]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF C C MANGUM HOLDINGS INC [EIN = 560586552]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF SAMUEL, SON & CO. MIDWEST [EIN = 341152823]
• GROUP INSURANCE PLAN FOR HOURLY EMPLOYEES OF CIBA SPECIALTY CHEMICALS CORPORATION AT MCINTOSH, AL [EIN = 133904291]
• GROUP INSURANCE FOR EMPLOYEES OF LOGISTICORP, LLC [EIN = 752784011]
• GROUP INSURANCE PLAN [EIN = 752858030]
• GROUP INSURANCE PLAN OF MORRIS BEAN & COMPANY [EIN = 310510640]
• GROUP INSURANCE PLAN [EIN = 824907031]
• GROUP INSURANCE PLAN OF BRIGGS & STRATTON LLC [EIN = 852711260]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF R.E. PIERSON COMPANIES [EIN = 222269412]
• GROUP INSURANCE PLAN FOR EMPLOYEES OF THE ESAB GROUP, INC. [EIN = 840966648]
• GROUP INSURANCE PLAN FOR CERTAIN EMPLOYEES OF MCC HOLDING COMPANY LLC [EIN = 854357999]
• GROUP INSURANCE PLAN FOR RETIRED SALARIED EMPLOYEES OF HARLEY-DAVIDSON MOTOR GROUP, INC. [EIN = 391972791]
• GROUP INSURANCE PLAN FOR RETIRED BARGAINING UNIT EMPLOYEES OF HARLEY DAVIDSON MOTOR COMPANY GROUP, INC. [EIN = 391972791]