FOOTHILL CARDIOLOGY MEDICAL GROUP, INC. has sponsored the creation of one or more 401k plans.
Additional information about FOOTHILL CARDIOLOGY MEDICAL GROUP, INC.
Submission information for form 5500 for 401k plan FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN
401k plan membership statisitcs for FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-07-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 109 |
| Number of retired or separated participants receiving benefits | 2022-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-07-01 | 0 |
| Total of all active and inactive participants | 2022-07-01 | 109 |
| 2015: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 122 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 73 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-07-01 | 5 |
| Total of all active and inactive participants | 2015-07-01 | 79 |
| Total participants | 2015-07-01 | 79 |
| 2014: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 119 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 119 |
| Number of retired or separated participants receiving benefits | 2014-07-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2014-07-01 | 0 |
| Total of all active and inactive participants | 2014-07-01 | 122 |
| Total participants | 2014-07-01 | 122 |
| 2013: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 119 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 115 |
| Number of retired or separated participants receiving benefits | 2013-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-07-01 | 3 |
| Total of all active and inactive participants | 2013-07-01 | 118 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2013-07-01 | 0 |
| Total participants | 2013-07-01 | 118 |
| 2012: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-07-01 | 125 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 117 |
| Number of retired or separated participants receiving benefits | 2012-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2012-07-01 | 1 |
| Total of all active and inactive participants | 2012-07-01 | 119 |
| Total participants | 2012-07-01 | 119 |
| 2011: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-07-01 | 119 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 118 |
| Number of retired or separated participants receiving benefits | 2011-07-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2011-07-01 | 4 |
| Total of all active and inactive participants | 2011-07-01 | 125 |
| Total participants | 2011-07-01 | 125 |
| 2010: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-07-01 | 116 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-07-01 | 117 |
| Number of retired or separated participants receiving benefits | 2010-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2010-07-01 | 0 |
| Total of all active and inactive participants | 2010-07-01 | 119 |
| Total participants | 2010-07-01 | 119 |
| 2009: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-07-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 115 |
| Number of retired or separated participants receiving benefits | 2009-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2009-07-01 | 0 |
| Total of all active and inactive participants | 2009-07-01 | 116 |
| Total participants | 2009-07-01 | 116 |
| 2022: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Submission has been amended | No |
| 2022-07-01 | This submission is the final filing | No |
| 2022-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-07-01 | Plan is a collectively bargained plan | No |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Submission has been amended | No |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Submission has been amended | No |
| 2014-07-01 | This submission is the final filing | No |
| 2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-07-01 | Plan is a collectively bargained plan | No |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Submission has been amended | No |
| 2012-07-01 | This submission is the final filing | No |
| 2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-07-01 | Plan is a collectively bargained plan | No |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | Submission has been amended | No |
| 2011-07-01 | This submission is the final filing | No |
| 2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-07-01 | Plan is a collectively bargained plan | No |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-07-01 | Type of plan entity | Single employer plan |
| 2010-07-01 | Submission has been amended | No |
| 2010-07-01 | This submission is the final filing | No |
| 2010-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-07-01 | Plan is a collectively bargained plan | No |
| 2010-07-01 | Plan funding arrangement – Insurance | Yes |
| 2010-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: FOOTHILL CARDIOLOGY/CALIFORNIA HEART MEDICAL GROUP WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-07-01 | Type of plan entity | Single employer plan |
| 2009-07-01 | First time form 5500 has been submitted | Yes |
| 2009-07-01 | Submission has been amended | No |
| 2009-07-01 | This submission is the final filing | No |
| 2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-07-01 | Plan is a collectively bargained plan | No |
| 2009-07-01 | Plan funding arrangement – Insurance | Yes |
| 2009-07-01 | Plan benefit arrangement – Insurance | Yes |
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 04768 |
| Policy instance | 4 |
| Insurance contract or identification number | 04768 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $4,042 | | 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 $80,845 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,042 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1142810 |
| Policy instance | 3 |
| Insurance contract or identification number | 1142810 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $4,935 | | Total amount of fees paid to insurance company | USD $307 | | 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 | Yes | | 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 $30,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,402 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 307 | | Additional information about fees paid to insurance broker | BONUS |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | C9314C/9320A |
| Policy instance | 2 |
| Insurance contract or identification number | C9314C/9320A | | Number of Individuals Covered | 71 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $35,248 | | 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 | Yes | | 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 $705,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,248 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 76472 |
| Policy instance | 1 |
| Insurance contract or identification number | 76472 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $293 | | 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 $2,930 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $293 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 278676 |
| Policy instance | 4 |
| Insurance contract or identification number | 278676 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $27,972 | | Total amount of fees paid to insurance company | USD $13,986 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | 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 $701,734 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,972 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS, OVERRIDE, NON-MONETARY COMPENSATION | | Insurance broker name | CENTERSTONE INSURANCE & FINANCIAL |
|
| THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70106 ) |
| Policy contract number | V225629 |
| Policy instance | 3 |
| Insurance contract or identification number | V225629 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $1,638 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,459 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,638 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM, INC. |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 04768 |
| Policy instance | 2 |
| Insurance contract or identification number | 04768 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $3,498 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $74,627 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,498 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM, INC. |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 76472 |
| Policy instance | 1 |
| Insurance contract or identification number | 76472 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $440 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,326 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $440 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM, INC. |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 278676 |
| Policy instance | 3 |
| Insurance contract or identification number | 278676 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $34,195 | | Total amount of fees paid to insurance company | USD $17,097 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $903,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,195 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS, OVERRIDE, NON-MONETARY COMPENSATION | | Insurance broker name | CENTERSTONE INSURANCE & FINANCIAL |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 04768 |
| Policy instance | 1 |
| Insurance contract or identification number | 04768 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $4,800 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $96,008 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,800 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM, INC. |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 76472 |
| Policy instance | 2 |
| Insurance contract or identification number | 76472 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $629 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,291 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $629 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM, INC. |
|
| THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70106 ) |
| Policy contract number | V225629 |
| Policy instance | 4 |
| Insurance contract or identification number | V225629 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $1,638 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,189 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,638 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM, INC. |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | H55506, 945522 |
| Policy instance | 1 |
| Insurance contract or identification number | H55506, 945522 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $33,545 | | Total amount of fees paid to insurance company | USD $16,773 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $838,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 16773 | | Additional information about fees paid to insurance broker | GENERAL AGENT SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | H55506, 945522 |
| Policy instance | 2 |
| Insurance contract or identification number | H55506, 945522 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $250 | | Total amount of fees paid to insurance company | USD $125 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH BENEFITS | | 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 $6,245 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 125 | | Additional information about fees paid to insurance broker | GENERAL AGENT SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 04768 |
| Policy instance | 3 |
| Insurance contract or identification number | 04768 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $4,613 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $92,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,613 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 76472 |
| Policy instance | 4 |
| Insurance contract or identification number | 76472 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $544 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $544 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | F31990 (25940) |
| Policy instance | 5 |
| Insurance contract or identification number | F31990 (25940) | | Number of Individuals Covered | 107 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $2,538 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,061 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $883 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM |
|
| THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70106 ) |
| Policy contract number | V225629 |
| Policy instance | 6 |
| Insurance contract or identification number | V225629 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $1,612 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH BENEFITS | | 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 $8,068 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,612 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 04768 |
| Policy instance | 3 |
| Insurance contract or identification number | 04768 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $4,728 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $94,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,728 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 76472 |
| Policy instance | 4 |
| Insurance contract or identification number | 76472 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $568 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,172 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $568 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | F31990 (25940) |
| Policy instance | 5 |
| Insurance contract or identification number | F31990 (25940) | | Number of Individuals Covered | 108 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $2,570 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,193 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,676 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ROGERS BENEFIT GROUP, INC. |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | H55506, 945522 |
| Policy instance | 2 |
| Insurance contract or identification number | H55506, 945522 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $248 | | Total amount of fees paid to insurance company | USD $124 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $6,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $248 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GENERAL AGENT SERVICES | | Insurance broker name | ROGERS BENEFIT GROUP, INC. |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | H55506, 945522 |
| Policy instance | 1 |
| Insurance contract or identification number | H55506, 945522 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $32,590 | | Total amount of fees paid to insurance company | USD $16,295 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $814,743 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,590 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GENERAL AGENT SERVICES | | Insurance broker name | ROGERS BENEFIT GROUP, INC. |
|
| THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70106 ) |
| Policy contract number | V225629 |
| Policy instance | 6 |
| Insurance contract or identification number | V225629 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $1,280 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $6,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,280 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSCAFE.COM |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 06472 |
| Policy instance | 5 |
| Insurance contract or identification number | 06472 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $641 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,407 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | H55506, 945522 |
| Policy instance | 1 |
| Insurance contract or identification number | H55506, 945522 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $38,534 | | Total amount of fees paid to insurance company | USD $23,581 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $769,293 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | H55506, 945522 |
| Policy instance | 2 |
| Insurance contract or identification number | H55506, 945522 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $314 | | Total amount of fees paid to insurance company | USD $126 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $6,278 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | F31990 (25940) |
| Policy instance | 3 |
| Insurance contract or identification number | F31990 (25940) | | Number of Individuals Covered | 104 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $2,311 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,038 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 04768 |
| Policy instance | 4 |
| Insurance contract or identification number | 04768 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $4,432 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $88,650 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70106 ) |
| Policy contract number | V225629 |
| Policy instance | 6 |
| Insurance contract or identification number | V225629 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-28 | | Total amount of commissions paid to insurance broker | USD $1,119 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $5,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 165342 |
| Policy instance | 1 |
| Insurance contract or identification number | 165342 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $43,181 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $849,310 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 6472 |
| Policy instance | 3 |
| Insurance contract or identification number | 6472 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $625 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,250 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70106 ) |
| Policy contract number | V225629 |
| Policy instance | 4 |
| Insurance contract or identification number | V225629 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $1,201 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $6,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 4768 |
| Policy instance | 2 |
| Insurance contract or identification number | 4768 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $4,360 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
