ALLEN MATKINS LECK GAMBLE MALLORY & NATSIS LLP has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN
| Measure | Date | Value |
|---|
| 2022: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 369 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 372 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 376 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 337 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 366 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 12 |
| Total of all active and inactive participants | 2021-01-01 | 384 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 378 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 330 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 337 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 357 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 369 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 378 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 358 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 346 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 357 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 355 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 352 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 358 |
| 2016: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 366 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 350 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 355 |
| 2015: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 365 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 361 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 366 |
| 2014: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 381 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 361 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 365 |
| 2013: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 446 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 368 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 13 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 381 |
| 2012: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 448 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 438 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 8 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| Total of all active and inactive participants | 2012-01-01 | 446 |
| 2011: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 447 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 438 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 10 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
| Total of all active and inactive participants | 2011-01-01 | 448 |
| 2010: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 458 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 438 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2010-01-01 | 0 |
| Total of all active and inactive participants | 2010-01-01 | 447 |
| 2009: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 413 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 436 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 22 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
| Total of all active and inactive participants | 2009-01-01 | 458 |
| 2022: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | Yes |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Submission has been amended | No |
| 2010-01-01 | This submission is the final filing | No |
| 2010-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-01-01 | Plan is a collectively bargained plan | No |
| 2010-01-01 | Plan funding arrangement – Insurance | Yes |
| 2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: AMLGMN HEALTH PLAN AMLGMN DENTAL PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | Yes |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 226164 |
| Policy instance | 6 |
| Insurance contract or identification number | 226164 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $59,524 | | Total amount of fees paid to insurance company | USD $250 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $1,452,345 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $55,927 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI960377 |
| Policy instance | 7 |
| Insurance contract or identification number | AI960377 | | Number of Individuals Covered | 372 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,377 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $55,986 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,377 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 633235 |
| Policy instance | 8 |
| Insurance contract or identification number | 633235 | | Number of Individuals Covered | 359 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $224,781 | | Total amount of fees paid to insurance company | USD $14,739 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $1,232,943 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $102,476 | | Amount paid for insurance broker fees | 11644 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| EMPATHIA PACIFIC, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 1 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 372 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $678 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $10,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $678 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 3795 |
| Policy instance | 2 |
| Insurance contract or identification number | 3795 | | Number of Individuals Covered | 764 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $42,934 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $429,341 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $42,934 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12276477 |
| Policy instance | 3 |
| Insurance contract or identification number | 12276477 | | Number of Individuals Covered | 349 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,759 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,862 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,611 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | G4P63 |
| Policy instance | 4 |
| Insurance contract or identification number | G4P63 | | Number of Individuals Covered | 372 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,802 | | Total amount of fees paid to insurance company | USD $68 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,654 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $491 | | Amount paid for insurance broker fees | 55 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 181218 |
| Policy instance | 5 |
| Insurance contract or identification number | 181218 | | Number of Individuals Covered | 523 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $140,000 | | Total amount of fees paid to insurance company | USD $10,000 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,380,841 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $140,000 | | Amount paid for insurance broker fees | 10000 | | Additional information about fees paid to insurance broker | 2022 Q1 GROW WITH US NEW BUSINESS INCENTIVE RISK | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339493 |
| Policy instance | 1 |
| Insurance contract or identification number | 3339493 | | Number of Individuals Covered | 535 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $116,670 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,945,434 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $116,670 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EMPATHIA PACIFIC, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 366 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $526 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $10,607 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $526 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 3795 |
| Policy instance | 3 |
| Insurance contract or identification number | 3795 | | Number of Individuals Covered | 729 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $40,158 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $385,074 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $40,158 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12276477 |
| Policy instance | 4 |
| Insurance contract or identification number | 12276477 | | Number of Individuals Covered | 346 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,658 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,819 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,658 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | G4P63 |
| Policy instance | 5 |
| Insurance contract or identification number | G4P63 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,289 | | Total amount of fees paid to insurance company | USD $36 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,636 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,052 | | Amount paid for insurance broker fees | 29 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 633235 |
| Policy instance | 6 |
| Insurance contract or identification number | 633235 | | Number of Individuals Covered | 332 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $166,135 | | Total amount of fees paid to insurance company | USD $9,029 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $933,274 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $91,232 | | Amount paid for insurance broker fees | 1016 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI960377 |
| Policy instance | 7 |
| Insurance contract or identification number | AI960377 | | Number of Individuals Covered | 344 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $7,207 | | Total amount of fees paid to insurance company | USD $1,321 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $48,046 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,207 | | Amount paid for insurance broker fees | 1121 | | Additional information about fees paid to insurance broker | OVERRIDES | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 226164 |
| Policy instance | 8 |
| Insurance contract or identification number | 226164 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $59,982 | | Total amount of fees paid to insurance company | USD $1,413 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $1,166,665 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $59,982 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 3795 |
| Policy instance | 3 |
| Insurance contract or identification number | 3795 | | Number of Individuals Covered | 719 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $40,063 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $400,631 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $40,063 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12276477 |
| Policy instance | 4 |
| Insurance contract or identification number | 12276477 | | Number of Individuals Covered | 330 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,512 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,696 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,512 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | G4P63 |
| Policy instance | 5 |
| Insurance contract or identification number | G4P63 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,356 | | Total amount of fees paid to insurance company | USD $28 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $576 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 226164 |
| Policy instance | 6 |
| Insurance contract or identification number | 226164 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $55,679 | | Total amount of fees paid to insurance company | USD $0 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $1,144,555 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $55,679 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 633235 |
| Policy instance | 7 |
| Insurance contract or identification number | 633235 | | Number of Individuals Covered | 332 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $113,370 | | Total amount of fees paid to insurance company | USD $13,972 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $667,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $111,777 | | Amount paid for insurance broker fees | 13972 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI960377 |
| Policy instance | 7 |
| Insurance contract or identification number | AI960377 | | Number of Individuals Covered | 330 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,908 | | Total amount of fees paid to insurance company | USD $1,151 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $39,386 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,908 | | Amount paid for insurance broker fees | 1151 | | Additional information about fees paid to insurance broker | OVERRIDES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 633235 |
| Policy instance | 8 |
| Insurance contract or identification number | 633235 | | Number of Individuals Covered | 332 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $173,918 | | Total amount of fees paid to insurance company | USD $13,972 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $959,894 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $172,325 | | Amount paid for insurance broker fees | 13972 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION , | | Insurance broker organization code? | 3 |
|
| EMPATHIA PACIFIC, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 354 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $399 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $10,554 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 399 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339493 |
| Policy instance | 1 |
| Insurance contract or identification number | 3339493 | | Number of Individuals Covered | 521 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $151,668 | | Total amount of fees paid to insurance company | USD $4,230 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,805,451 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $151,668 | | Amount paid for insurance broker fees | 4230 | | Additional information about fees paid to insurance broker | SERVICE/GENERAL AGENT FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI960377 |
| Policy instance | 8 |
| Insurance contract or identification number | AI960377 | | Number of Individuals Covered | 330 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,908 | | Total amount of fees paid to insurance company | USD $1,151 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $39,386 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,908 | | Amount paid for insurance broker fees | 1151 | | Additional information about fees paid to insurance broker | OVERRIDES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI960377 |
| Policy instance | 8 |
| Insurance contract or identification number | AI960377 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,197 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $34,647 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,197 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339493 |
| Policy instance | 1 |
| Insurance contract or identification number | 3339493 | | Number of Individuals Covered | 528 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $128,320 | | Total amount of fees paid to insurance company | USD $4,671 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,402,738 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $81,659 | | Amount paid for insurance broker fees | 4671 | | Additional information about fees paid to insurance broker | SERVICE/GENERAL AGENT FEES | | Insurance broker organization code? | 3 |
|
| EMPATHIA PACIFIC, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 376 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $533 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $10,663 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $533 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12276477 |
| Policy instance | 4 |
| Insurance contract or identification number | 12276477 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,594 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,172 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,594 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 3795 |
| Policy instance | 3 |
| Insurance contract or identification number | 3795 | | Number of Individuals Covered | 738 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $40,079 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $400,786 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $40,079 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | G4P63 |
| Policy instance | 5 |
| Insurance contract or identification number | G4P63 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,611 | | Total amount of fees paid to insurance company | USD $15 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,478 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $778 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 226164 |
| Policy instance | 6 |
| Insurance contract or identification number | 226164 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $47,837 | | Total amount of fees paid to insurance company | USD $0 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $1,022,007 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $47,837 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 633235 |
| Policy instance | 7 |
| Insurance contract or identification number | 633235 | | Number of Individuals Covered | 359 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $124,837 | | Total amount of fees paid to insurance company | USD $9,309 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $708,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $124,837 | | Amount paid for insurance broker fees | 9309 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339493 |
| Policy instance | 1 |
| Insurance contract or identification number | 3339493 | | Number of Individuals Covered | 528 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $151,664 | | Total amount of fees paid to insurance company | USD $1,354 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,237,740 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $151,664 | | Amount paid for insurance broker fees | 1354 | | Additional information about fees paid to insurance broker | SERVICE/GENERAL AGENT FEES | | Insurance broker organization code? | 3 |
|
| EMPATHIA PACIFIC, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 360 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $647 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $12,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $647 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 3795 |
| Policy instance | 3 |
| Insurance contract or identification number | 3795 | | Number of Individuals Covered | 760 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $34,619 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $346,188 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $34,619 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12276477 |
| Policy instance | 4 |
| Insurance contract or identification number | 12276477 | | Number of Individuals Covered | 346 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,589 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,913 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,589 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | G4P63 |
| Policy instance | 5 |
| Insurance contract or identification number | G4P63 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,114 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,413 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $930 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 633235 |
| Policy instance | 6 |
| Insurance contract or identification number | 633235 | | Number of Individuals Covered | 347 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $121,537 | | Total amount of fees paid to insurance company | USD $8,620 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $743,261 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $121,537 | | Amount paid for insurance broker fees | 8620 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 226164 |
| Policy instance | 7 |
| Insurance contract or identification number | 226164 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $55,518 | | Total amount of fees paid to insurance company | USD $0 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $1,119,661 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $55,518 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI960377 |
| Policy instance | 8 |
| Insurance contract or identification number | AI960377 | | Number of Individuals Covered | 346 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $6,413 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $29,256 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,413 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EMPATHIA PACIFIC, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 2 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 363 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $615 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $12,298 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $615 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 3795 |
| Policy instance | 3 |
| Insurance contract or identification number | 3795 | | Number of Individuals Covered | 726 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $34,709 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $347,088 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $34,709 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12276477 |
| Policy instance | 4 |
| Insurance contract or identification number | 12276477 | | Number of Individuals Covered | 347 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,588 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,879 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,588 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | G4P63 |
| Policy instance | 5 |
| Insurance contract or identification number | G4P63 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $3,988 | | Total amount of fees paid to insurance company | USD $513 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,994 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,331 | | Amount paid for insurance broker fees | 297 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ADAM H. MICHAELS |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 633235 |
| Policy instance | 6 |
| Insurance contract or identification number | 633235 | | Number of Individuals Covered | 399 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $127,195 | | Total amount of fees paid to insurance company | USD $9,350 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $699,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $127,195 | | Amount paid for insurance broker fees | 9350 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TBG WEST INSURANCE SERVICE |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 226164 |
| Policy instance | 7 |
| Insurance contract or identification number | 226164 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $44,474 | | Total amount of fees paid to insurance company | USD $0 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $893,966 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,474 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI960377 |
| Policy instance | 8 |
| Insurance contract or identification number | AI960377 | | Number of Individuals Covered | 352 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $7,659 | | Total amount of fees paid to insurance company | USD $1,401 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $80,414 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,659 | | Amount paid for insurance broker fees | 1401 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339493 |
| Policy instance | 1 |
| Insurance contract or identification number | 3339493 | | Number of Individuals Covered | 551 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $140,014 | | Total amount of fees paid to insurance company | USD $1,327 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,503,026 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $140,014 | | Amount paid for insurance broker fees | 1327 | | Additional information about fees paid to insurance broker | SERVICE/GENERAL AGENT FEES | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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