ANITA'S MEXICAN FOODS CORP. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN
Measure | Date | Value |
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2021: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-09-01 | 534 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-09-01 | 499 |
Number of retired or separated participants receiving benefits | 2021-09-01 | 3 |
Number of other retired or separated participants entitled to future benefits | 2021-09-01 | 0 |
Total of all active and inactive participants | 2021-09-01 | 502 |
2020: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-09-01 | 574 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 532 |
Number of retired or separated participants receiving benefits | 2020-09-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2020-09-01 | 0 |
Total of all active and inactive participants | 2020-09-01 | 534 |
2019: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-09-01 | 210 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 574 |
Number of retired or separated participants receiving benefits | 2019-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2019-09-01 | 0 |
Total of all active and inactive participants | 2019-09-01 | 574 |
2018: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-09-01 | 113 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 210 |
Number of retired or separated participants receiving benefits | 2018-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
Total of all active and inactive participants | 2018-09-01 | 210 |
2017: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-09-01 | 175 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 113 |
Number of retired or separated participants receiving benefits | 2017-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 0 |
Total of all active and inactive participants | 2017-09-01 | 113 |
2016: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-09-01 | 183 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 175 |
Number of retired or separated participants receiving benefits | 2016-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2016-09-01 | 0 |
Total of all active and inactive participants | 2016-09-01 | 175 |
2015: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-09-01 | 179 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 183 |
Total of all active and inactive participants | 2015-09-01 | 183 |
Total participants | 2015-09-01 | 183 |
2014: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-09-01 | 80 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 179 |
Total of all active and inactive participants | 2014-09-01 | 179 |
Total participants | 2014-09-01 | 0 |
2013: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-09-01 | 98 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-09-01 | 80 |
Total of all active and inactive participants | 2013-09-01 | 80 |
Total participants | 2013-09-01 | 0 |
2012: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-09-01 | 129 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 98 |
Total of all active and inactive participants | 2012-09-01 | 98 |
Total participants | 2012-09-01 | 0 |
2011: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-01-01 | 128 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 129 |
Total of all active and inactive participants | 2011-01-01 | 129 |
Total participants | 2011-01-01 | 129 |
2010: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2010 401k membership |
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Total participants, beginning-of-year | 2010-09-01 | 68 |
Total number of active participants reported on line 7a of the Form 5500 | 2010-09-01 | 128 |
Total of all active and inactive participants | 2010-09-01 | 128 |
Total participants | 2010-09-01 | 128 |
2009: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-09-01 | 38 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-09-01 | 68 |
Total of all active and inactive participants | 2009-09-01 | 68 |
Total participants | 2009-09-01 | 68 |
Measure | Date | Value |
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2016 : ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2016 401k financial data |
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Total unrealized appreciation/depreciation of assets | 2016-08-31 | $0 |
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-08-31 | $0 |
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-08-31 | $0 |
Total income from all sources (including contributions) | 2016-08-31 | $973,483 |
Total loss/gain on sale of assets | 2016-08-31 | $0 |
Total of all expenses incurred | 2016-08-31 | $973,483 |
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-08-31 | $973,483 |
Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-08-31 | $973,483 |
Value of total assets at end of year | 2016-08-31 | $0 |
Value of total assets at beginning of year | 2016-08-31 | $0 |
Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-08-31 | $0 |
Total interest from all sources | 2016-08-31 | $0 |
Total dividends received (eg from common stock, registered investment company shares) | 2016-08-31 | $0 |
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-08-31 | No |
Was this plan covered by a fidelity bond | 2016-08-31 | No |
Were there any nonexempt tranactions with any party-in-interest | 2016-08-31 | No |
Contributions received from participants | 2016-08-31 | $249,758 |
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-08-31 | No |
Value of net income/loss | 2016-08-31 | $0 |
Value of net assets at end of year (total assets less liabilities) | 2016-08-31 | $0 |
Value of net assets at beginning of year (total assets less liabilities) | 2016-08-31 | $0 |
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-08-31 | No |
Were any loans by the plan or fixed income obligations due to the plan in default | 2016-08-31 | No |
Were any leases to which the plan was party in default or uncollectible | 2016-08-31 | No |
Expenses. Payments to insurance carriers foe the provision of benefits | 2016-08-31 | $973,483 |
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-08-31 | No |
Was there a failure to transmit to the plan any participant contributions | 2016-08-31 | No |
Has the plan failed to provide any benefit when due under the plan | 2016-08-31 | No |
Contributions received in cash from employer | 2016-08-31 | $723,725 |
Did the plan have assets held for investment | 2016-08-31 | No |
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-08-31 | No |
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-08-31 | No |
2015 : ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2015 401k financial data |
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Total income from all sources | 2015-08-31 | $606,430 |
Expenses. Total of all expenses incurred | 2015-08-31 | $606,430 |
Benefits paid (including direct rollovers) | 2015-08-31 | $606,430 |
Total contributions received or receivable from participants | 2015-08-31 | $170,442 |
Total contributions received or receivable from employer(s) | 2015-08-31 | $435,988 |
2014 : ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2014 401k financial data |
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Total income from all sources | 2014-08-31 | $302,989 |
Expenses. Total of all expenses incurred | 2014-08-31 | $302,989 |
Benefits paid (including direct rollovers) | 2014-08-31 | $302,989 |
Total contributions received or receivable from participants | 2014-08-31 | $89,471 |
Total contributions received or receivable from employer(s) | 2014-08-31 | $213,518 |
2013 : ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2013 401k financial data |
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Total income from all sources | 2013-08-31 | $312,092 |
Expenses. Total of all expenses incurred | 2013-08-31 | $312,092 |
Benefits paid (including direct rollovers) | 2013-08-31 | $312,092 |
Total contributions received or receivable from participants | 2013-08-31 | $120,279 |
Total contributions received or receivable from employer(s) | 2013-08-31 | $191,813 |
2011 : ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2011 401k financial data |
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Total income from all sources | 2011-12-31 | $313,057 |
Expenses. Total of all expenses incurred | 2011-12-31 | $313,057 |
Benefits paid (including direct rollovers) | 2011-12-31 | $313,057 |
Total contributions received or receivable from participants | 2011-12-31 | $52,480 |
Total contributions received or receivable from employer(s) | 2011-12-31 | $260,577 |
Total income from all sources | 2011-08-31 | $255,956 |
Expenses. Total of all expenses incurred | 2011-08-31 | $255,956 |
Benefits paid (including direct rollovers) | 2011-08-31 | $255,956 |
Total contributions received or receivable from participants | 2011-08-31 | $69,277 |
Total contributions received or receivable from employer(s) | 2011-08-31 | $186,679 |
2021: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2021 form 5500 responses |
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2021-09-01 | Type of plan entity | Single employer plan |
2021-09-01 | Submission has been amended | No |
2021-09-01 | This submission is the final filing | No |
2021-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-09-01 | Plan is a collectively bargained plan | No |
2021-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-09-01 | Plan benefit arrangement – Insurance | Yes |
2021-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2020 form 5500 responses |
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2020-09-01 | Type of plan entity | Single employer plan |
2020-09-01 | Submission has been amended | No |
2020-09-01 | This submission is the final filing | No |
2020-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-09-01 | Plan is a collectively bargained plan | No |
2020-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-09-01 | Plan benefit arrangement – Insurance | Yes |
2020-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2019 form 5500 responses |
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2019-09-01 | Type of plan entity | Single employer plan |
2019-09-01 | Submission has been amended | No |
2019-09-01 | This submission is the final filing | No |
2019-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-09-01 | Plan is a collectively bargained plan | No |
2019-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-09-01 | Plan benefit arrangement – Insurance | Yes |
2019-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2018 form 5500 responses |
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2018-09-01 | Type of plan entity | Single employer plan |
2018-09-01 | Submission has been amended | No |
2018-09-01 | This submission is the final filing | No |
2018-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-09-01 | Plan is a collectively bargained plan | No |
2018-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-09-01 | Plan benefit arrangement – Insurance | Yes |
2018-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2017: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2017 form 5500 responses |
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2017-09-01 | Type of plan entity | Single employer plan |
2017-09-01 | Submission has been amended | No |
2017-09-01 | This submission is the final filing | No |
2017-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-09-01 | Plan is a collectively bargained plan | No |
2017-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-09-01 | Plan benefit arrangement – Insurance | Yes |
2017-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2016: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2016 form 5500 responses |
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2016-09-01 | Type of plan entity | Single employer plan |
2016-09-01 | Submission has been amended | No |
2016-09-01 | This submission is the final filing | No |
2016-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-09-01 | Plan is a collectively bargained plan | No |
2016-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2016-09-01 | Plan benefit arrangement – Insurance | Yes |
2016-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2015: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2015 form 5500 responses |
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2015-09-01 | Type of plan entity | Single employer plan |
2015-09-01 | Submission has been amended | No |
2015-09-01 | This submission is the final filing | No |
2015-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-09-01 | Plan is a collectively bargained plan | No |
2015-09-01 | Plan funding arrangement – Insurance | Yes |
2015-09-01 | Plan benefit arrangement – Insurance | Yes |
2014: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2014 form 5500 responses |
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2014-09-01 | Type of plan entity | Single employer plan |
2014-09-01 | Plan funding arrangement – Insurance | Yes |
2014-09-01 | Plan benefit arrangement – Insurance | Yes |
2013: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2013 form 5500 responses |
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2013-09-01 | Type of plan entity | Single employer plan |
2013-09-01 | Plan funding arrangement – Insurance | Yes |
2013-09-01 | Plan benefit arrangement – Insurance | Yes |
2012: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2012 form 5500 responses |
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2012-09-01 | Type of plan entity | Single employer plan |
2012-09-01 | Plan funding arrangement – Insurance | Yes |
2012-09-01 | Plan benefit arrangement – Insurance | Yes |
2011: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2011 form 5500 responses |
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2011-01-01 | Type of plan entity | Single employer plan |
2011-01-01 | Plan funding arrangement – Insurance | Yes |
2011-01-01 | Plan benefit arrangement – Insurance | Yes |
2010: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2010 form 5500 responses |
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2010-09-01 | Type of plan entity | Single employer plan |
2010-09-01 | Plan funding arrangement – Insurance | Yes |
2010-09-01 | Plan benefit arrangement – Insurance | Yes |
2009: ANITAS MEXICAN FOODS FLEXIBLE BENEFIT PLAN 2009 form 5500 responses |
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2009-09-01 | Type of plan entity | Single employer plan |
2009-09-01 | Plan funding arrangement – Insurance | Yes |
2009-09-01 | Plan benefit arrangement – Insurance | Yes |
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 232548 |
Policy instance | 10 |
Insurance contract or identification number | 232548 | Number of Individuals Covered | 218 | Insurance policy start date | 2021-03-01 | Insurance policy end date | 2022-02-28 | Total amount of commissions paid to insurance broker | USD $64,988 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,384,410 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $64,988 | Insurance broker organization code? | 3 |
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CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
Policy contract number | W0003548 |
Policy instance | 1 |
Insurance contract or identification number | W0003548 | Number of Individuals Covered | 2 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2022-08-31 | Total amount of commissions paid to insurance broker | USD $13,239 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $188,262 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,239 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0BL9V |
Policy instance | 2 |
Insurance contract or identification number | GLTD0BL9V | Number of Individuals Covered | 1 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2022-08-31 | Total amount of commissions paid to insurance broker | USD $15 | Total amount of fees paid to insurance company | USD $138 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $101 | 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 | Amount paid for insurance broker fees | 138 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 860382 |
Policy instance | 3 |
Insurance contract or identification number | 860382 | Number of Individuals Covered | 46 | Insurance policy start date | 2021-03-01 | Insurance policy end date | 2022-02-28 | Total amount of commissions paid to insurance broker | USD $1,110 | Total amount of fees paid to insurance company | USD $58 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Welfare Benefit Premiums Paid to Carrier | USD $10,653 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,110 | Amount paid for insurance broker fees | 58 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUPR0BL9V |
Policy instance | 4 |
Insurance contract or identification number | GUPR0BL9V | Number of Individuals Covered | 114 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2022-08-31 | Total amount of commissions paid to insurance broker | USD $5,815 | Total amount of fees paid to insurance company | USD $3,198 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $38,765 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,815 | Amount paid for insurance broker fees | 3198 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
Policy contract number | 829789 |
Policy instance | 5 |
Insurance contract or identification number | 829789 | Number of Individuals Covered | 170 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2022-02-28 | Total amount of commissions paid to insurance broker | USD $767 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $7,655 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $775 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BL9V |
Policy instance | 6 |
Insurance contract or identification number | GVTL0BL9V | Number of Individuals Covered | 248 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2022-08-31 | Total amount of commissions paid to insurance broker | USD $7,320 | Total amount of fees paid to insurance company | USD $4,401 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 & 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 $48,799 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,320 | Amount paid for insurance broker fees | 4401 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 860382 |
Policy instance | 7 |
Insurance contract or identification number | 860382 | Number of Individuals Covered | 195 | Insurance policy start date | 2021-03-01 | Insurance policy end date | 2022-02-28 | Total amount of commissions paid to insurance broker | USD $17,977 | Total amount of fees paid to insurance company | USD $900 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Welfare Benefit Premiums Paid to Carrier | USD $183,703 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,977 | Amount paid for insurance broker fees | 900 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BL9V |
Policy instance | 8 |
Insurance contract or identification number | GLUG0BL9V | Number of Individuals Covered | 499 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2022-08-31 | Total amount of commissions paid to insurance broker | USD $1,673 | Total amount of fees paid to insurance company | USD $877 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 & 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 $11,150 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,673 | Amount paid for insurance broker fees | 877 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 139022 |
Policy instance | 9 |
Insurance contract or identification number | 139022 | Number of Individuals Covered | 40 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $13,712 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $263,886 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,712 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 232548 |
Policy instance | 2 |
Insurance contract or identification number | 232548 | Number of Individuals Covered | 238 | Insurance policy start date | 2020-03-01 | Insurance policy end date | 2021-02-28 | Total amount of commissions paid to insurance broker | USD $84,139 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,688,157 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $84,139 | Insurance broker organization code? | 3 |
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CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
Policy contract number | W0003548 |
Policy instance | 3 |
Insurance contract or identification number | W0003548 | Number of Individuals Covered | 6 | Insurance policy start date | 2020-09-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $9,216 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $130,960 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,216 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BL9V |
Policy instance | 4 |
Insurance contract or identification number | GVTL0BL9V | Number of Individuals Covered | 235 | Insurance policy start date | 2020-09-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $12,360 | Total amount of fees paid to insurance company | USD $4,968 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 & 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 $82,402 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,360 | Amount paid for insurance broker fees | 4968 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 139022 |
Policy instance | 5 |
Insurance contract or identification number | 139022 | Number of Individuals Covered | 51 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $12,240 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $233,382 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,240 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUPR0BL9V |
Policy instance | 6 |
Insurance contract or identification number | GUPR0BL9V | Number of Individuals Covered | 152 | Insurance policy start date | 2020-09-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $8,855 | Total amount of fees paid to insurance company | USD $3,224 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $59,030 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,855 | Amount paid for insurance broker fees | 3224 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BL9V |
Policy instance | 7 |
Insurance contract or identification number | GLUG0BL9V | Number of Individuals Covered | 532 | Insurance policy start date | 2020-09-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $2,610 | Total amount of fees paid to insurance company | USD $967 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 & 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 $17,398 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,610 | Amount paid for insurance broker fees | 967 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0BL9V |
Policy instance | 8 |
Insurance contract or identification number | GLTD0BL9V | Number of Individuals Covered | 0 | Insurance policy start date | 2020-09-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $510 | Total amount of fees paid to insurance company | USD $181 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $3,403 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $510 | Amount paid for insurance broker fees | 181 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 860382 |
Policy instance | 9 |
Insurance contract or identification number | 860382 | Number of Individuals Covered | 207 | Insurance policy start date | 2020-03-01 | Insurance policy end date | 2021-02-28 | Total amount of commissions paid to insurance broker | USD $19,239 | Total amount of fees paid to insurance company | USD $76 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Welfare Benefit Premiums Paid to Carrier | USD $195,359 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $19,239 | Amount paid for insurance broker fees | 76 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
Policy contract number | 829789 |
Policy instance | 1 |
Insurance contract or identification number | 829789 | Number of Individuals Covered | 192 | Insurance policy start date | 2020-09-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $2,312 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $22,786 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,321 | Insurance broker organization code? | 3 |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 860382 |
Policy instance | 10 |
Insurance contract or identification number | 860382 | Number of Individuals Covered | 57 | Insurance policy start date | 2020-03-01 | Insurance policy end date | 2021-02-28 | Total amount of commissions paid to insurance broker | USD $1,046 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Welfare Benefit Premiums Paid to Carrier | USD $12,742 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,046 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 232548 |
Policy instance | 1 |
Insurance contract or identification number | 232548 | Number of Individuals Covered | 230 | Insurance policy start date | 2019-03-01 | Insurance policy end date | 2020-02-29 | Total amount of commissions paid to insurance broker | USD $58,469 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,169,674 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $52,871 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BL9V |
Policy instance | 2 |
Insurance contract or identification number | GVTL0BL9V | Number of Individuals Covered | 293 | Insurance policy start date | 2019-09-01 | Insurance policy end date | 2020-08-31 | Total amount of commissions paid to insurance broker | USD $13,683 | Total amount of fees paid to insurance company | USD $1,519 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 & 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 $91,219 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,683 | Amount paid for insurance broker fees | 1519 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 860382 |
Policy instance | 3 |
Insurance contract or identification number | 860382 | Number of Individuals Covered | 219 | Insurance policy start date | 2019-09-01 | Insurance policy end date | 2020-02-29 | Total amount of commissions paid to insurance broker | USD $10,173 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Welfare Benefit Premiums Paid to Carrier | USD $99,049 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,173 | Insurance broker organization code? | 3 |
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CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
Policy contract number | W0003548 |
Policy instance | 4 |
Insurance contract or identification number | W0003548 | Number of Individuals Covered | 4 | Insurance policy start date | 2019-09-01 | Insurance policy end date | 2020-08-31 | Total amount of commissions paid to insurance broker | USD $9,578 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $136,167 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,578 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BL9V |
Policy instance | 5 |
Insurance contract or identification number | GLUG0BL9V | Number of Individuals Covered | 574 | Insurance policy start date | 2019-09-01 | Insurance policy end date | 2020-08-31 | Total amount of commissions paid to insurance broker | USD $2,664 | Total amount of fees paid to insurance company | USD $306 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 & 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 $17,762 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,664 | Amount paid for insurance broker fees | 306 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0BL9V |
Policy instance | 6 |
Insurance contract or identification number | GLTD0BL9V | Number of Individuals Covered | 80 | Insurance policy start date | 2019-09-01 | Insurance policy end date | 2020-08-31 | Total amount of commissions paid to insurance broker | USD $480 | Total amount of fees paid to insurance company | USD $45 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $3,200 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $480 | Amount paid for insurance broker fees | 45 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUPR0BL9V |
Policy instance | 7 |
Insurance contract or identification number | GUPR0BL9V | Number of Individuals Covered | 245 | Insurance policy start date | 2019-09-01 | Insurance policy end date | 2020-08-31 | Total amount of commissions paid to insurance broker | USD $8,855 | Total amount of fees paid to insurance company | USD $1,009 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $59,032 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,855 | Amount paid for insurance broker fees | 1009 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 139022 |
Policy instance | 8 |
Insurance contract or identification number | 139022 | Number of Individuals Covered | 28 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $9,840 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $160,174 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,840 | Insurance broker organization code? | 3 |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 860382 |
Policy instance | 9 |
Insurance contract or identification number | 860382 | Number of Individuals Covered | 67 | Insurance policy start date | 2019-09-01 | Insurance policy end date | 2020-02-29 | Total amount of commissions paid to insurance broker | USD $652 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Welfare Benefit Premiums Paid to Carrier | USD $6,442 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $652 | Insurance broker organization code? | 3 |
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HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
Policy contract number | 829789 |
Policy instance | 10 |
Insurance contract or identification number | 829789 | Number of Individuals Covered | 209 | Insurance policy start date | 2019-09-01 | Insurance policy end date | 2020-08-31 | Total amount of commissions paid to insurance broker | USD $1,026 | Total amount of fees paid to insurance company | USD $377 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $10,649 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,026 | Amount paid for insurance broker fees | 377 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 860382 |
Policy instance | 2 |
Insurance contract or identification number | 860382 | Number of Individuals Covered | 175 | Insurance policy start date | 2018-09-01 | Insurance policy end date | 2019-08-31 | Total amount of commissions paid to insurance broker | USD $19,917 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Welfare Benefit Premiums Paid to Carrier | USD $189,666 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,844 | Insurance broker organization code? | 3 |
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CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
Policy contract number | W0003548 |
Policy instance | 1 |
Insurance contract or identification number | W0003548 | Number of Individuals Covered | 6 | Insurance policy start date | 2018-09-01 | Insurance policy end date | 2019-08-31 | Total amount of commissions paid to insurance broker | USD $6,255 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $176,440 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,255 | Insurance broker organization code? | 3 |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 860382 |
Policy instance | 3 |
Insurance contract or identification number | 860382 | Number of Individuals Covered | 35 | Insurance policy start date | 2018-09-01 | Insurance policy end date | 2019-08-31 | Total amount of commissions paid to insurance broker | USD $988 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Welfare Benefit Premiums Paid to Carrier | USD $9,499 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $655 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 232548 |
Policy instance | 4 |
Insurance contract or identification number | 232548 | Number of Individuals Covered | 255 | Insurance policy start date | 2018-03-01 | Insurance policy end date | 2019-02-28 | Total amount of commissions paid to insurance broker | USD $61,804 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,184,853 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $61,804 | Insurance broker organization code? | 3 |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 860382 |
Policy instance | 4 |
Insurance contract or identification number | 860382 | Number of Individuals Covered | 26 | Insurance policy start date | 2017-09-01 | Insurance policy end date | 2018-08-31 | Total amount of commissions paid to insurance broker | USD $482 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Welfare Benefit Premiums Paid to Carrier | USD $5,403 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
Policy contract number | W0003548 |
Policy instance | 3 |
Insurance contract or identification number | W0003548 | Number of Individuals Covered | 7 | Insurance policy start date | 2017-09-01 | Insurance policy end date | 2018-08-31 | Total amount of commissions paid to insurance broker | USD $11,683 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $166,009 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 860382 |
Policy instance | 1 |
Insurance contract or identification number | 860382 | Number of Individuals Covered | 87 | Insurance policy start date | 2017-09-01 | Insurance policy end date | 2018-08-31 | Total amount of commissions paid to insurance broker | USD $9,847 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Welfare Benefit Premiums Paid to Carrier | USD $105,442 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 232548 |
Policy instance | 2 |
Insurance contract or identification number | 232548 | Number of Individuals Covered | 217 | Insurance policy start date | 2017-03-01 | Insurance policy end date | 2018-02-28 | Total amount of commissions paid to insurance broker | USD $45,714 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $955,554 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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