401k Plan data: STURGEON & SON, INC. WELFARE BENEFIT PLAN plan

STURGEON & SON, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	STURGEON & SON, INC. WELFARE BENEFIT PLAN
Plan identification number	501

STURGEON & SON, INC. WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Supplemental unemployment Dental Vision Temporary disability (accident and sickness) Long-term disability cover

401k Sponsoring company profile

STURGEON SERVICES INT'L INC. has sponsored the creation of one or more 401k plans.

Company Name: STURGEON SERVICES INT'L INC.

Employer identification number (EIN): 952852054

NAIC Classification: 237310
NAIC Description: Highway, Street, and Bridge Construction

Additional information about STURGEON SERVICES INT'L INC.

Jurisdiction of Incorporation: California Department of State

Incorporation Date: 1972-10-06

Company Identification Number: C0666815

Legal Registered Office Address: 3511 Gilmore Ave

Bakersfield
United States of America (USA)
93308

More information about STURGEON SERVICES INT'L INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan STURGEON & SON, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 DIXIE HERNANDEZ DIXIE HERNANDEZ 2018-10-14
501 2016-01-01 CORRINA SHERIDAN CORRINA SHERIDAN 2017-10-13
501 2015-01-01 CORRINA SHERIDAN CORRINA SHERIDAN 2017-01-27
501 2014-01-01 GREGORY ROWLAND GREGORY ROWLAND 2015-07-16
501 2013-01-01 GREGORY ROWLAND GREGORY ROWLAND 2014-10-06
501 2012-01-01 GREGORY ROWLAND GREGORY ROWLAND 2013-10-15
501 2011-01-01 GREGORY ROWLAND GREGORY ROWLAND 2012-10-12

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	DIXIE HERNANDEZ	DIXIE HERNANDEZ	2018-10-14
501	2016-01-01	CORRINA SHERIDAN	CORRINA SHERIDAN	2017-10-13
501	2015-01-01	CORRINA SHERIDAN	CORRINA SHERIDAN	2017-01-27
501	2014-01-01	GREGORY ROWLAND	GREGORY ROWLAND	2015-07-16
501	2013-01-01	GREGORY ROWLAND	GREGORY ROWLAND	2014-10-06
501	2012-01-01	GREGORY ROWLAND	GREGORY ROWLAND	2013-10-15
501	2011-01-01	GREGORY ROWLAND	GREGORY ROWLAND	2012-10-12

Plan Statistics for STURGEON & SON, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for STURGEON & SON, INC. WELFARE BENEFIT PLAN

Measure Date Value
2021: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 630
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 467
Number of retired or separated participants receiving benefits 2021-01-01 1
Total of all active and inactive participants 2021-01-01 468
2020: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 555
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 630
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 630
2019: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 533
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 555
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 555
2018: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 488
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 533
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 533
2017: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 591
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 488
Total of all active and inactive participants 2017-01-01 488
2016: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 612
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 591
Total of all active and inactive participants 2016-01-01 591
2015: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 852
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 611
Number of other retired or separated participants entitled to future benefits 2015-01-01 1
Total of all active and inactive participants 2015-01-01 612
2014: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 882
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 850
Number of retired or separated participants receiving benefits 2014-01-01 2
Total of all active and inactive participants 2014-01-01 852
2013: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 713
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 882
Total of all active and inactive participants 2013-01-01 882
2012: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 584
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 713
Total of all active and inactive participants 2012-01-01 713
2011: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 415
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 584
Total of all active and inactive participants 2011-01-01 584

Measure	Date	Value
2021: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	630
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	467
Number of retired or separated participants receiving benefits	2021-01-01	1
Total of all active and inactive participants	2021-01-01	468
2020: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	555
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	630
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	630
2019: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	533
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	555
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	555
2018: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	488
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	533
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	533
2017: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	591
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	488
Total of all active and inactive participants	2017-01-01	488
2016: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	612
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	591
Total of all active and inactive participants	2016-01-01	591
2015: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	852
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	611
Number of other retired or separated participants entitled to future benefits	2015-01-01	1
Total of all active and inactive participants	2015-01-01	612
2014: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	882
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	850
Number of retired or separated participants receiving benefits	2014-01-01	2
Total of all active and inactive participants	2014-01-01	852
2013: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	713
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	882
Total of all active and inactive participants	2013-01-01	882
2012: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	584
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	713
Total of all active and inactive participants	2012-01-01	713
2011: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	415
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	584
Total of all active and inactive participants	2011-01-01	584

Form 5500 Responses for STURGEON & SON, INC. WELFARE BENEFIT PLAN

2021: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: STURGEON & SON, INC. WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

G0360

Policy instance

Insurance contract or identification number	G0360
Number of Individuals Covered	77
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $79,762
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $338,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $79,762
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

A18380-000

Policy instance

Insurance contract or identification number	A18380-000
Number of Individuals Covered	387
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $14,612
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $148,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,612
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

034431

Policy instance

Insurance contract or identification number	034431
Number of Individuals Covered	149
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,411
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,411
Insurance broker organization code?	3

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

Policy contract number

GLUG0AZ6K

Policy instance

Insurance contract or identification number	GLUG0AZ6K
Number of Individuals Covered	205
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,284
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,284
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4531992

Policy instance

Insurance contract or identification number	E4531992
Number of Individuals Covered	82
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $13,706
Total amount of fees paid to insurance company	USD $212
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPPTL INSURANCE PD BY EMPLOYEE
Welfare Benefit Premiums Paid to Carrier	USD $120,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,621
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

G0200

Policy instance

Insurance contract or identification number	G0200
Number of Individuals Covered	397
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $15,952
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,237,006
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	15952
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4531992

Policy instance

Insurance contract or identification number	E4531992
Number of Individuals Covered	103
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $32,838
Total amount of fees paid to insurance company	USD $1,978
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPPTL INSURANCE PD BY EMPLOYEE
Welfare Benefit Premiums Paid to Carrier	USD $32,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,978
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

GLUG0AZ6K

Policy instance

Insurance contract or identification number	GLUG0AZ6K
Number of Individuals Covered	222
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,662
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,662
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

034431

Policy instance

Insurance contract or identification number	034431
Number of Individuals Covered	193
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,614
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,614
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

A18380-000

Policy instance

Insurance contract or identification number	A18380-000
Number of Individuals Covered	494
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $18,909
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $186,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,909
Insurance broker organization code?	3

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

Policy contract number

G0360

Policy instance

Insurance contract or identification number	G0360
Number of Individuals Covered	67
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $71,116
Total amount of fees paid to insurance company	USD $21,232
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $196,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $71,116
Amount paid for insurance broker fees	21232
Insurance broker organization code?	3

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

Policy contract number

G0200

Policy instance

Insurance contract or identification number	G0200
Number of Individuals Covered	547
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $14,223
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,351,728
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	14223
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

Q57-37733

Policy instance

Insurance contract or identification number	Q57-37733
Number of Individuals Covered	20
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $653
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $653

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

Policy contract number

G0360

Policy instance

Insurance contract or identification number	G0360
Number of Individuals Covered	57
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,063
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,063
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

G0200

Policy instance

Insurance contract or identification number	G0200
Number of Individuals Covered	600
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 $1,413
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,548
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	1413

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

Q53-37689

Policy instance

Insurance contract or identification number	Q53-37689
Number of Individuals Covered	182
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $12,875
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $128,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,875
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0065585

Policy instance

Insurance contract or identification number	W0065585
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,073
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,226,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,073
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

34431

Policy instance

Insurance contract or identification number	34431
Number of Individuals Covered	214
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,911
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,911
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

GLUG0AZ6K

Policy instance

Insurance contract or identification number	GLUG0AZ6K
Number of Individuals Covered	295
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,378
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,378
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4531992

Policy instance

Insurance contract or identification number	E4531992
Number of Individuals Covered	140
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $20,882
Total amount of fees paid to insurance company	USD $1,344
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPPTL INSURANCE PD BY EMPLOYEE
Welfare Benefit Premiums Paid to Carrier	USD $147,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,153
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

A18380-000

Policy instance

Insurance contract or identification number	A18380-000
Number of Individuals Covered	582
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ADMINISTRATIVE SOLUTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

MEDICAL

Policy instance

Insurance contract or identification number	MEDICAL
Number of Individuals Covered	9
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,140
Total amount of fees paid to insurance company	USD $3,240
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,140
Amount paid for insurance broker fees	3240

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4531992

Policy instance

Insurance contract or identification number	E4531992
Number of Individuals Covered	125
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $49,909
Total amount of fees paid to insurance company	USD $10,861
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPPTL INSURANCE PD BY EMPLOYEE
Welfare Benefit Premiums Paid to Carrier	USD $171,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,091
Insurance broker organization code?	3
Amount paid for insurance broker fees	5015

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

Policy contract number

GLUG0AZ6K

Policy instance

Insurance contract or identification number	GLUG0AZ6K
Number of Individuals Covered	224
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,235
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,235
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

34431

Policy instance

Insurance contract or identification number	34431
Number of Individuals Covered	176
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,970
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,970
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

Q53-37689

Policy instance

Insurance contract or identification number	Q53-37689
Number of Individuals Covered	453
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $17,657
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $176,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,657
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0065585

Policy instance

Insurance contract or identification number	W0065585
Number of Individuals Covered	382
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $70,408
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,408,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $70,408
Insurance broker organization code?	3

ADMINISTRATIVE SOLUTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

HRA

Policy instance

Insurance contract or identification number	HRA
Number of Individuals Covered	259
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $224,157
Total amount of fees paid to insurance company	USD $13,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $224,157
Amount paid for insurance broker fees	13825
Insurance broker name	CLIFFORD & BRADFORD INSURANCE AGENC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

34431

Policy instance

Insurance contract or identification number	34431
Number of Individuals Covered	649
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,330
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,330
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	WES BRADFORD INSURANCE SALES, INC

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

Policy contract number

GLUG0AZ6K

Policy instance

Insurance contract or identification number	GLUG0AZ6K
Number of Individuals Covered	325
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,626
Total amount of fees paid to insurance company	USD $1,023
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,626
Amount paid for insurance broker fees	1023
Insurance broker organization code?	3
Insurance broker name	WES BRADFORD INSURANCE SALES INC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4531992

Policy instance

Insurance contract or identification number	E4531992
Number of Individuals Covered	98
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $31,249
Total amount of fees paid to insurance company	USD $10,984
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPPTL INSURANCE PD BY EMPLOYEE
Welfare Benefit Premiums Paid to Carrier	USD $118,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,507
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SONNA S GIDEONS

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

919499

Policy instance

Insurance contract or identification number	919499
Number of Individuals Covered	812
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $20,853
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $203,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,853
Amount paid for insurance broker fees	0
Insurance broker name	WES BRADFORD INSURANCE SALES INC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

228898

Policy instance

Insurance contract or identification number	228898
Number of Individuals Covered	483
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $112,810
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,126,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $112,810
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	WES BRADFORD INSURANCE SALES, INC.

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

4W722/DL4436

Policy instance

Insurance contract or identification number	4W722/DL4436
Number of Individuals Covered	920
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $17,034
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $720,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,924
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LPL FINANCIAL CORP

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

BV442

Policy instance

Insurance contract or identification number	BV442
Number of Individuals Covered	178
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $26,940
Total amount of fees paid to insurance company	USD $638
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $176,337
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,511
Amount paid for insurance broker fees	351
Insurance broker organization code?	3
Insurance broker name	ANDREW M. SIMMONS

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

V8435

Policy instance

Insurance contract or identification number	V8435
Number of Individuals Covered	11
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,654
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $485
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	D BREDESON INSURANCE SERVICES INC.

TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )

Policy contract number

0345800000

Policy instance

Insurance contract or identification number	0345800000
Number of Individuals Covered	472
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $53,996
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $201,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,795
Insurance broker organization code?	3
Insurance broker name	INSURANCE ASSIST, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

228898

Policy instance

Insurance contract or identification number	228898
Number of Individuals Covered	1446
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $300,627
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,999,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $235,690
Insurance broker organization code?	3
Insurance broker name	CLIFFORD & BRADFORD INS

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

V8435

Policy instance

Insurance contract or identification number	V8435
Number of Individuals Covered	8
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,101
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $271
Insurance broker organization code?	3
Insurance broker name	LORENZO HERRERA

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

BV442

Policy instance

Insurance contract or identification number	BV442
Number of Individuals Covered	215
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $32,398
Total amount of fees paid to insurance company	USD $2,756
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $173,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,498
Amount paid for insurance broker fees	1497
Insurance broker organization code?	3
Insurance broker name	HEALTHLAND INS. SRVCS., INC.

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

0004W722

Policy instance

Insurance contract or identification number	0004W722
Number of Individuals Covered	982
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $20,910
Total amount of fees paid to insurance company	USD $6,844
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $930,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,910
Amount paid for insurance broker fees	6844
Insurance broker organization code?	3
Insurance broker name	INSURANCE ASSIST, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

228898

Policy instance

Insurance contract or identification number	228898
Number of Individuals Covered	1973
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $287,781
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,255,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $287,781
Insurance broker organization code?	3
Insurance broker name	INSURANCEASSIST, INC.

TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )

Policy contract number

0345800000

Policy instance

Insurance contract or identification number	0345800000
Number of Individuals Covered	649
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $151,026
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $193,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $105,711
Insurance broker organization code?	3
Insurance broker name	INSURANCE ASSIST, INC.

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

577450

Policy instance

Insurance contract or identification number	577450
Number of Individuals Covered	83
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $24,076
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $264,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,853
Insurance broker organization code?	3
Insurance broker name	ROGERS BENEFIT GROUP INC.

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

068456

Policy instance

Insurance contract or identification number	068456
Number of Individuals Covered	933
Insurance policy start date	2013-04-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,558
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,558
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	INSURANCEASSIST INC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

228898

Policy instance

Insurance contract or identification number	228898
Number of Individuals Covered	2006
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $234,009
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,207,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $233,570
Insurance broker organization code?	3
Insurance broker name	MIKE PONCE

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

BV442

Policy instance

Insurance contract or identification number	BV442
Number of Individuals Covered	354
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $62,446
Total amount of fees paid to insurance company	USD $510
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $301,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,492
Amount paid for insurance broker fees	303
Insurance broker organization code?	3
Insurance broker name	ANDREW M. SIMMONS

ADMINISTRATIVE SOLUTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

95-2852054

Policy instance

Insurance contract or identification number	95-2852054
Number of Individuals Covered	795
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 $52,950
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $828,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	52950
Additional information about fees paid to insurance broker	ADMIN
Insurance broker organization code?	3
Insurance broker name	INASSIST INSURANCE SERVICES

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

V8435

Policy instance

Insurance contract or identification number	V8435
Number of Individuals Covered	11
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,542
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $418
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LORENZO HERRERA

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

0004W722

Policy instance

Insurance contract or identification number	0004W722
Number of Individuals Covered	855
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $14,535
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $768,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,535
Insurance broker organization code?	3
Insurance broker name	INSURANCE ASSIST, INC.

ADMINISTRATIVE SOLUTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

6003

Policy instance

Insurance contract or identification number	6003
Number of Individuals Covered	24
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 $8,588
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $115,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	8588
Additional information about fees paid to insurance broker	ADMIN
Insurance broker organization code?	3
Insurance broker name	INASSIST INSURANCE SERVICES

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

BV442

Policy instance

Insurance contract or identification number	BV442
Number of Individuals Covered	358
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $50,425
Total amount of fees paid to insurance company	USD $158
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $256,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,025
Amount paid for insurance broker fees	113
Additional information about fees paid to insurance broker	ADMIN
Insurance broker organization code?	3
Insurance broker name	LAVONNE MCCUMBER

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

068456

Policy instance

Insurance contract or identification number	068456
Number of Individuals Covered	824
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $2,788
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,973
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	INSURANCEASSIST INC

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

DL459

Policy instance

Insurance contract or identification number	DL459
Number of Individuals Covered	710
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $13,164
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $640,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,164
Insurance broker organization code?	3
Insurance broker name	MIKE PONCE

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

Policy instance

Number of Individuals Covered	1748
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $181,286
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,389,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $181,286
Insurance broker organization code?	3
Insurance broker name	MIKE PONCE

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

210-823/210-824

Policy instance

Insurance contract or identification number	210-823/210-824
Number of Individuals Covered	224
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,398
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

BV442

Policy instance

Insurance contract or identification number	BV442
Number of Individuals Covered	318
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $53,949
Total amount of fees paid to insurance company	USD $2,051
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $221,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

068456

Policy instance

Insurance contract or identification number	068456
Number of Individuals Covered	386
Insurance policy start date	2011-04-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $1,323
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,363
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

Policy instance

Number of Individuals Covered	534
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $143,584
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,525,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

DL459

Policy instance

Insurance contract or identification number	DL459
Number of Individuals Covered	540
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $8,560
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $437,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

STURGEON & BECK, INC. 401(K) SAVINGS PLAN [EIN = 941496283]

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Company Name:	STURGEON SERVICES INT'L INC.
Employer identification number (EIN):	952852054
NAIC Classification:	237310
NAIC Description:	Highway, Street, and Bridge Construction

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:	1972-10-06
Company Identification Number:	C0666815
Legal Registered Office Address:	3511 Gilmore Ave Bakersfield United States of America (USA) 93308