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METAL SURFACES EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan NameMETAL SURFACES EMPLOYEE BENEFIT PLAN
Plan identification number 501

METAL SURFACES EMPLOYEE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

METAL SURFACES INTERNATIONAL, LLC has sponsored the creation of one or more 401k plans.

Company Name:METAL SURFACES INTERNATIONAL, LLC
Employer identification number (EIN):953867836
NAIC Classification:332810

Form 5500 Filing Information

Submission information for form 5500 for 401k plan METAL SURFACES EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-06-01NANCY NASCIMENTO2023-12-18
5012021-06-01NANCY NASCIMENTO2022-12-12
5012020-06-01VIVIAN OROZCO2022-02-23
5012019-06-01
5012019-06-01NANCY NASCIMENTO2022-07-07
5012018-06-01
5012018-06-01NANCY NASCIMENTO2022-07-07
5012017-06-01NELL WALLACE
5012017-06-01NANCY NASCIMENTO2022-07-07
5012016-06-01NELL WALLACE
5012016-06-01NANCY NASCIMENTO2022-07-07
5012015-06-01NELL WALLACE
5012015-06-01NANCY NASCIMENTO2022-07-15
5012014-06-01ALAN ERLANDSON
5012014-06-01NANCY NASCIMENTO2022-07-15
5012013-06-01CRAIG K. SNYDER
5012013-06-01NANCY NASCIMENTO2022-07-07
5012012-06-01CRAIG K. SNYDER
5012011-06-01CRAIG K SNYDER
5012009-06-01CRAIG K SNYDER

Plan Statistics for METAL SURFACES EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for METAL SURFACES EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: METAL SURFACES EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-06-01117
Total number of active participants reported on line 7a of the Form 55002022-06-01105
Number of retired or separated participants receiving benefits2022-06-010
Number of other retired or separated participants entitled to future benefits2022-06-010
Total of all active and inactive participants2022-06-01105
Number of employers contributing to the scheme2022-06-010
2021: METAL SURFACES EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-06-01115
Total number of active participants reported on line 7a of the Form 55002021-06-01117
Number of retired or separated participants receiving benefits2021-06-010
Number of other retired or separated participants entitled to future benefits2021-06-010
Total of all active and inactive participants2021-06-01117
Number of employers contributing to the scheme2021-06-010
2020: METAL SURFACES EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-06-01110
Total number of active participants reported on line 7a of the Form 55002020-06-01106
Number of retired or separated participants receiving benefits2020-06-010
Number of other retired or separated participants entitled to future benefits2020-06-010
Total of all active and inactive participants2020-06-01106
Number of employers contributing to the scheme2020-06-010
2019: METAL SURFACES EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-06-01115
Total number of active participants reported on line 7a of the Form 55002019-06-01111
Total of all active and inactive participants2019-06-01111
Total participants2019-06-01111
Number of retired or separated participants receiving benefits2019-06-010
Number of other retired or separated participants entitled to future benefits2019-06-010
Number of employers contributing to the scheme2019-06-010
2018: METAL SURFACES EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-06-01120
Total number of active participants reported on line 7a of the Form 55002018-06-01115
Total of all active and inactive participants2018-06-01115
Total participants2018-06-01115
Number of retired or separated participants receiving benefits2018-06-010
Number of other retired or separated participants entitled to future benefits2018-06-010
Number of employers contributing to the scheme2018-06-010
2017: METAL SURFACES EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-06-01122
Total number of active participants reported on line 7a of the Form 55002017-06-01120
Number of retired or separated participants receiving benefits2017-06-011
Total of all active and inactive participants2017-06-01121
Total participants2017-06-01121
Number of other retired or separated participants entitled to future benefits2017-06-010
Number of employers contributing to the scheme2017-06-010
2016: METAL SURFACES EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-06-01115
Total number of active participants reported on line 7a of the Form 55002016-06-01122
Total of all active and inactive participants2016-06-01122
Total participants2016-06-01122
Number of retired or separated participants receiving benefits2016-06-010
Number of other retired or separated participants entitled to future benefits2016-06-010
Number of employers contributing to the scheme2016-06-010
2015: METAL SURFACES EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-06-01115
Total number of active participants reported on line 7a of the Form 55002015-06-01115
Total of all active and inactive participants2015-06-01115
Total participants2015-06-010
Number of retired or separated participants receiving benefits2015-06-010
Number of other retired or separated participants entitled to future benefits2015-06-010
Number of employers contributing to the scheme2015-06-010
2014: METAL SURFACES EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-06-01116
Total number of active participants reported on line 7a of the Form 55002014-06-01115
Total of all active and inactive participants2014-06-01115
Total participants2014-06-010
Number of retired or separated participants receiving benefits2014-06-010
Number of other retired or separated participants entitled to future benefits2014-06-010
Number of employers contributing to the scheme2014-06-010
2013: METAL SURFACES EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-06-01116
Total number of active participants reported on line 7a of the Form 55002013-06-01116
Total of all active and inactive participants2013-06-01116
Total participants2013-06-010
Number of retired or separated participants receiving benefits2013-06-010
Number of other retired or separated participants entitled to future benefits2013-06-010
Number of employers contributing to the scheme2013-06-010
2012: METAL SURFACES EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-06-01116
Total number of active participants reported on line 7a of the Form 55002012-06-01126
Total of all active and inactive participants2012-06-01126
Total participants2012-06-010
2011: METAL SURFACES EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-06-01118
Total number of active participants reported on line 7a of the Form 55002011-06-01116
Total of all active and inactive participants2011-06-01116
Total participants2011-06-01116
2009: METAL SURFACES EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-06-01120
Total number of active participants reported on line 7a of the Form 55002009-06-01117
Total of all active and inactive participants2009-06-01117
Total participants2009-06-01117

Form 5500 Responses for METAL SURFACES EMPLOYEE BENEFIT PLAN

2022: METAL SURFACES EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-06-01Type of plan entitySingle employer plan
2022-06-01Plan funding arrangement – InsuranceYes
2022-06-01Plan benefit arrangement – InsuranceYes
2021: METAL SURFACES EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-06-01Type of plan entitySingle employer plan
2021-06-01Plan funding arrangement – InsuranceYes
2021-06-01Plan benefit arrangement – InsuranceYes
2020: METAL SURFACES EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-06-01Type of plan entitySingle employer plan
2020-06-01Plan funding arrangement – InsuranceYes
2020-06-01Plan benefit arrangement – InsuranceYes
2019: METAL SURFACES EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-06-01Type of plan entitySingle employer plan
2019-06-01Submission has been amendedYes
2019-06-01Plan funding arrangement – InsuranceYes
2019-06-01Plan benefit arrangement – InsuranceYes
2018: METAL SURFACES EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Submission has been amendedYes
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan benefit arrangement – InsuranceYes
2017: METAL SURFACES EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-06-01Type of plan entitySingle employer plan
2017-06-01Submission has been amendedYes
2017-06-01Plan funding arrangement – InsuranceYes
2017-06-01Plan benefit arrangement – InsuranceYes
2016: METAL SURFACES EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-06-01Type of plan entitySingle employer plan
2016-06-01Submission has been amendedYes
2016-06-01Plan funding arrangement – InsuranceYes
2016-06-01Plan benefit arrangement – InsuranceYes
2015: METAL SURFACES EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01Submission has been amendedYes
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – InsuranceYes
2014: METAL SURFACES EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-06-01Type of plan entitySingle employer plan
2014-06-01Submission has been amendedYes
2014-06-01Plan funding arrangement – InsuranceYes
2014-06-01Plan benefit arrangement – InsuranceYes
2013: METAL SURFACES EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-06-01Type of plan entitySingle employer plan
2013-06-01Submission has been amendedYes
2013-06-01Plan funding arrangement – InsuranceYes
2013-06-01Plan benefit arrangement – InsuranceYes
2012: METAL SURFACES EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-06-01Type of plan entitySingle employer plan
2012-06-01Plan funding arrangement – InsuranceYes
2012-06-01Plan benefit arrangement – InsuranceYes
2011: METAL SURFACES EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-06-01Type of plan entitySingle employer plan
2011-06-01Plan funding arrangement – InsuranceYes
2011-06-01Plan benefit arrangement – InsuranceYes
2009: METAL SURFACES EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-06-01Type of plan entitySingle employer plan
2009-06-01Plan funding arrangement – InsuranceYes
2009-06-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 2
Insurance contract or identification number225907
Number of Individuals Covered52
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $13,169
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $312,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,169
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0066818
Policy instance 1
Insurance contract or identification numberW0066818
Number of Individuals Covered63
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $21,238
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $403,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees21238
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number136-421567
Policy instance 3
Insurance contract or identification number136-421567
Number of Individuals Covered151
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $9,198
Total amount of fees paid to insurance companyUSD $1,882
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT,CRITICAL ILLNESS,HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $81,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,703
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number136-421567
Policy instance 3
Insurance contract or identification number136-421567
Number of Individuals Covered134
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $23,122
Total amount of fees paid to insurance companyUSD $2,121
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT,CRITICAL ILLNESS,HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $84,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,446
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 2
Insurance contract or identification number225907
Number of Individuals Covered42
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $14,380
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $337,605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,051
Amount paid for insurance broker fees0
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0066818
Policy instance 1
Insurance contract or identification numberW0066818
Number of Individuals Covered62
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $17,977
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $344,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees17977
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0066818
Policy instance 1
Insurance contract or identification numberW0066818
Number of Individuals Covered53
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $17,631
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $332,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees17631
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 2
Insurance contract or identification number225907
Number of Individuals Covered71
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $17,667
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $477,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,667
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number98184021001
Policy instance 3
Insurance contract or identification number98184021001
Number of Individuals Covered30
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $267
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $267
Amount paid for insurance broker fees0
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number5753499
Policy instance 4
Insurance contract or identification number5753499
Number of Individuals Covered59
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $974
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $974
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM604301
Policy instance 5
Insurance contract or identification numberSGM604301
Number of Individuals Covered106
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $3,754
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $25,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $3,754
Amount paid for insurance broker fees0
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE7228562
Policy instance 8
Insurance contract or identification numberE7228562
Number of Individuals Covered22
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $4,243
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER
Welfare Benefit Premiums Paid to CarrierUSD $26,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,003
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD604323
Policy instance 7
Insurance contract or identification numberSGD604323
Number of Individuals Covered25
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $492
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $492
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK602842
Policy instance 6
Insurance contract or identification numberSOK602842
Number of Individuals Covered111
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $189
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $189
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM604301
Policy instance 5
Insurance contract or identification numberSGM604301
Number of Individuals Covered111
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $3,074
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,074
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number5753499
Policy instance 4
Insurance contract or identification number5753499
Number of Individuals Covered37
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $1,155
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,155
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number98184021001
Policy instance 3
Insurance contract or identification number98184021001
Number of Individuals Covered36
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $245
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $245
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 2
Insurance contract or identification number225907
Number of Individuals Covered50
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $17,442
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $445,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,442
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberK6H64
Policy instance 9
Insurance contract or identification numberK6H64
Number of Individuals Covered2
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $511
Total amount of fees paid to insurance companyUSD $76
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER
Welfare Benefit Premiums Paid to CarrierUSD $1,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $361
Amount paid for insurance broker fees54
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberKPL11
Policy instance 10
Insurance contract or identification numberKPL11
Number of Individuals Covered38
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $4,362
Total amount of fees paid to insurance companyUSD $263
Welfare Benefit Premiums Paid to CarrierUSD $31,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,317
Amount paid for insurance broker fees193
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0066818
Policy instance 1
Insurance contract or identification numberW0066818
Number of Individuals Covered40
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of fees paid to insurance companyUSD $17,701
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $336,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees17701
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKMO5753499
Policy instance 1
Insurance contract or identification numberKMO5753499
Number of Individuals Covered43
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $1,193
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,991
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,193
Insurance broker organization code?4
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKM05753499
Policy instance 1
Insurance contract or identification numberKM05753499
Number of Individuals Covered43
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $1,193
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,991
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,193
Amount paid for insurance broker fees0
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberKPL11 & K6H64
Policy instance 7
Insurance contract or identification numberKPL11 & K6H64
Number of Individuals Covered41
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $5,371
Total amount of fees paid to insurance companyUSD $266
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $29,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,006
Amount paid for insurance broker fees188
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE7228562
Policy instance 6
Insurance contract or identification numberE7228562
Number of Individuals Covered13
Insurance policy start date2018-02-01
Insurance policy end date2019-01-31
Total amount of commissions paid to insurance brokerUSD $975
Total amount of fees paid to insurance companyUSD $4
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $18,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $704
Amount paid for insurance broker fees4
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 4
Insurance contract or identification number225907
Number of Individuals Covered73
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $18,444
Welfare Benefit Premiums Paid to CarrierUSD $471,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,444
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Amount paid for insurance broker fees0
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number98184021001
Policy instance 3
Insurance contract or identification number98184021001
Number of Individuals Covered31
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $269
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $269
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Amount paid for insurance broker fees0
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVARIOUS
Policy instance 2
Insurance contract or identification numberVARIOUS
Number of Individuals Covered115
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $5,844
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $38,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,844
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $594
Amount paid for insurance broker fees594
Additional information about fees paid to insurance brokerSALES INCENTIVE
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0066818
Policy instance 5
Insurance contract or identification numberW0066818
Number of Individuals Covered39
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $15,521
Welfare Benefit Premiums Paid to CarrierUSD $310,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,521
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Amount paid for insurance broker fees0
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKMO5753499
Policy instance 1
Insurance contract or identification numberKMO5753499
Number of Individuals Covered43
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,234
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,234
Insurance broker organization code?4
Insurance broker nameJOHN M. GILMOUR, INC.
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberKPL11 & K6H64
Policy instance 7
Insurance contract or identification numberKPL11 & K6H64
Number of Individuals Covered40
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $11,661
Total amount of fees paid to insurance companyUSD $807
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $24,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,856
Amount paid for insurance broker fees299
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Insurance broker nameCHRISTOPHER MATTHEW PORTEOUS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE7228562
Policy instance 6
Insurance contract or identification numberE7228562
Number of Individuals Covered13
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $2,225
Total amount of fees paid to insurance companyUSD $1
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $19,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,567
Amount paid for insurance broker fees1
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Insurance broker nameHOLLER & ASSOCIATES INC.
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberG0013A & 69677A
Policy instance 5
Insurance contract or identification numberG0013A & 69677A
Number of Individuals Covered39
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $17,824
Welfare Benefit Premiums Paid to CarrierUSD $356,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,824
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Amount paid for insurance broker fees0
Insurance broker nameJOHN M. GILMOUR, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 4
Insurance contract or identification number225907
Number of Individuals Covered47
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $19,545
Total amount of fees paid to insurance companyUSD $1
Welfare Benefit Premiums Paid to CarrierUSD $499,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,545
Amount paid for insurance broker fees1
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Health Insurance Welfare BenefitYes
Insurance broker nameBENEFITS AMERICA INSURANCE SERVICES
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number98184021001
Policy instance 3
Insurance contract or identification number98184021001
Number of Individuals Covered35
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $322
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $322
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Amount paid for insurance broker fees0
Insurance broker nameBENEFITS AMERICA INSURANCE SERVICES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVARIOUS
Policy instance 2
Insurance contract or identification numberVARIOUS
Number of Individuals Covered120
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $5,686
Total amount of fees paid to insurance companyUSD $594
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $37,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,686
Amount paid for insurance broker fees594
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Insurance broker nameBENEFITS AMERICA INSURANCE SERVICES
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKM05753499
Policy instance 1
Insurance contract or identification numberKM05753499
Number of Individuals Covered43
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,234
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,234
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 3
Insurance contract or identification number225907
Number of Individuals Covered57
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $19,131
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $493,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,131
Amount paid for insurance broker fees0
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberVARIOUS
Policy instance 4
Insurance contract or identification numberVARIOUS
Number of Individuals Covered40
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $16,345
Total amount of fees paid to insurance companyUSD $720
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $326,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,345
Amount paid for insurance broker fees720
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKM05753499
Policy instance 5
Insurance contract or identification numberKM05753499
Number of Individuals Covered122
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $1,539
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,539
Amount paid for insurance broker fees0
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE7228562
Policy instance 6
Insurance contract or identification numberE7228562
Number of Individuals Covered16
Insurance policy start date2016-02-01
Insurance policy end date2017-01-31
Total amount of commissions paid to insurance brokerUSD $1,412
Total amount of fees paid to insurance companyUSD $88
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER
Welfare Benefit Premiums Paid to CarrierUSD $20,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $932
Amount paid for insurance broker fees84
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9818402
Policy instance 2
Insurance contract or identification number9818402
Number of Individuals Covered41
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $364
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $364
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVARIOUS
Policy instance 1
Insurance contract or identification numberVARIOUS
Number of Individuals Covered116
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $5,114
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,114
Amount paid for insurance broker fees0
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKM05753499
Policy instance 5
Insurance contract or identification numberKM05753499
Number of Individuals Covered47
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $1,241
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,241
Amount paid for insurance broker fees0
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberVARIOUS
Policy instance 4
Insurance contract or identification numberVARIOUS
Number of Individuals Covered40
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $17,625
Total amount of fees paid to insurance companyUSD $1,088
Welfare Benefit Premiums Paid to CarrierUSD $352,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,625
Amount paid for insurance broker fees1088
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Health Insurance Welfare BenefitYes
Insurance broker nameJOHN M. GILMOUR, INC.
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9818402
Policy instance 2
Insurance contract or identification number9818402
Number of Individuals Covered44
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $314
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $314
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Amount paid for insurance broker fees0
Insurance broker nameBENEFITS AMERICA INSURANCE SERVICES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVARIOUS
Policy instance 1
Insurance contract or identification numberVARIOUS
Number of Individuals Covered116
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $5,114
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,114
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $360
Amount paid for insurance broker fees360
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker nameBENEFITS AMERICA INSURANCE SERVICES
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKMO5753499
Policy instance 5
Insurance contract or identification numberKMO5753499
Number of Individuals Covered47
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $1,241
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,241
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE7228562
Policy instance 6
Insurance contract or identification numberE7228562
Number of Individuals Covered23
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $3,259
Total amount of fees paid to insurance companyUSD $560
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $23,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,270
Amount paid for insurance broker fees539
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Insurance broker nameJOEL NEIL NEWMAN
COLONIAL LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62047 )
Policy contract numberE7228562
Policy instance 6
Insurance contract or identification numberE7228562
Number of Individuals Covered23
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $3,259
Total amount of fees paid to insurance companyUSD $560
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER
Welfare Benefit Premiums Paid to CarrierUSD $23,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,270
Amount paid for insurance broker fees539
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 3
Insurance contract or identification number225907
Number of Individuals Covered55
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $18,274
Welfare Benefit Premiums Paid to CarrierUSD $470,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,738
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Amount paid for insurance broker fees0
Insurance broker nameJOHN M. GILMOUR, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVARIOUS
Policy instance 1
Insurance contract or identification numberVARIOUS
Number of Individuals Covered113
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $6,152
Total amount of fees paid to insurance companyUSD $360
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $41,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,152
Amount paid for insurance broker fees360
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameBENEFITS AMERICA INSURANCE SERVICES
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9818402
Policy instance 2
Insurance contract or identification number9818402
Number of Individuals Covered48
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $350
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $254
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Amount paid for insurance broker fees0
Insurance broker nameBENEFITS AMERICA INSURANCE SERVICES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 3
Insurance contract or identification number225907
Number of Individuals Covered53
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $17,620
Welfare Benefit Premiums Paid to CarrierUSD $451,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,620
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Amount paid for insurance broker fees0
Insurance broker nameJOHN M. GILMOUR, INC.
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberVARIOUS
Policy instance 4
Insurance contract or identification numberVARIOUS
Number of Individuals Covered45
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $18,449
Total amount of fees paid to insurance companyUSD $282
Welfare Benefit Premiums Paid to CarrierUSD $366,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,449
Amount paid for insurance broker fees282
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Health Insurance Welfare BenefitYes
Insurance broker nameJOHN M. GILMOUR, INC.
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKMO5753499
Policy instance 5
Insurance contract or identification numberKMO5753499
Number of Individuals Covered56
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $1,388
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,388
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE7228562
Policy instance 6
Insurance contract or identification numberE7228562
Number of Individuals Covered23
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $3,071
Total amount of fees paid to insurance companyUSD $351
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $23,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,902
Amount paid for insurance broker fees299
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Insurance broker nameHOLLERN & ASSOCIATES INCORPORTATED
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKM05753499
Policy instance 5
Insurance contract or identification numberKM05753499
Number of Individuals Covered56
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $1,388
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,388
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9818402
Policy instance 2
Insurance contract or identification number9818402
Number of Individuals Covered51
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $442
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $442
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Amount paid for insurance broker fees0
Insurance broker nameJOHN M. GILMOUR, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 3
Insurance contract or identification number225907
Number of Individuals Covered62
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $18,517
Welfare Benefit Premiums Paid to CarrierUSD $475,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,517
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Amount paid for insurance broker fees0
Insurance broker nameJOHN M. GILMOUR, INC.
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKMO5753499
Policy instance 5
Insurance contract or identification numberKMO5753499
Number of Individuals Covered56
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $1,574
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,574
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberVARIOUS
Policy instance 4
Insurance contract or identification numberVARIOUS
Number of Individuals Covered45
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $16,317
Welfare Benefit Premiums Paid to CarrierUSD $355,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,317
Insurance broker organization code?3
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Amount paid for insurance broker fees0
Insurance broker nameJOHN M. GILMOUR, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVARIOUS
Policy instance 1
Insurance contract or identification numberVARIOUS
Number of Individuals Covered116
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $4,758
Total amount of fees paid to insurance companyUSD $605
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $31,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,758
Amount paid for insurance broker fees605
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE7228562
Policy instance 6
Insurance contract or identification numberE7228562
Number of Individuals Covered21
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $2,183
Total amount of fees paid to insurance companyUSD $298
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $21,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,284
Amount paid for insurance broker fees272
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Insurance broker nameGLENN HOLLERN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0267F
Policy instance 1
Insurance contract or identification numberGLUG0267F
Number of Individuals Covered116
Insurance policy start date2013-06-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0267F
Policy instance 7
Insurance contract or identification numberGLTD0267F
Number of Individuals Covered116
Insurance policy start date2013-06-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKM05753499
Policy instance 5
Insurance contract or identification numberKM05753499
Number of Individuals Covered56
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $1,574
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,574
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0267F
Policy instance 8
Insurance contract or identification numberGVTL0267F
Number of Individuals Covered116
Insurance policy start date2013-06-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberVARIOUS
Policy instance 3
Insurance contract or identification numberVARIOUS
Number of Individuals Covered44
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $14,093
Welfare Benefit Premiums Paid to CarrierUSD $251,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,093
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 4
Insurance contract or identification number225907
Number of Individuals Covered65
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $17,199
Welfare Benefit Premiums Paid to CarrierUSD $434,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,199
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKMO5753499
Policy instance 2
Insurance contract or identification numberKMO5753499
Number of Individuals Covered57
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $1,508
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,508
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000267F
Policy instance 6
Insurance contract or identification numberG000267F
Number of Individuals Covered126
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $4,739
Total amount of fees paid to insurance companyUSD $684
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,739
Amount paid for insurance broker fees684
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE7228562
Policy instance 1
Insurance contract or identification numberE7228562
Number of Individuals Covered22
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $1,268
Total amount of fees paid to insurance companyUSD $98
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $20,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7
Insurance broker organization code?3
Amount paid for insurance broker fees1
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker nameABRAMS MARKETING, INC.
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9818402
Policy instance 5
Insurance contract or identification number9818402
Number of Individuals Covered31
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $404
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $404
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE7228562
Policy instance 2
Insurance contract or identification numberE7228562
Number of Individuals Covered21
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $1,547
Total amount of fees paid to insurance companyUSD $92
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $20,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9818402
Policy instance 1
Insurance contract or identification number9818402
Number of Individuals Covered32
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $330
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,299
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 number151735
Policy instance 6
Insurance contract or identification number151735
Number of Individuals Covered116
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $12,738
Total amount of fees paid to insurance companyUSD $4,612
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $236,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 5
Insurance contract or identification number225907
Number of Individuals Covered75
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $20,491
Welfare Benefit Premiums Paid to CarrierUSD $503,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000267F
Policy instance 4
Insurance contract or identification numberG000267F
Number of Individuals Covered39
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $4,007
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number5753499
Policy instance 3
Insurance contract or identification number5753499
Number of Individuals Covered52
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $1,125
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,430
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 number151735
Policy instance 6
Insurance contract or identification number151735
Number of Individuals Covered118
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $16,962
Total amount of fees paid to insurance companyUSD $2,609
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $316,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10700-1000
Policy instance 1
Insurance contract or identification number10700-1000
Number of Individuals Covered35
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $1,231
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000267F
Policy instance 4
Insurance contract or identification numberG000267F
Number of Individuals Covered39
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $3,166
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number5753499
Policy instance 3
Insurance contract or identification number5753499
Number of Individuals Covered54
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE7228562
Policy instance 2
Insurance contract or identification numberE7228562
Number of Individuals Covered20
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Total amount of commissions paid to insurance brokerUSD $1,183
Total amount of fees paid to insurance companyUSD $26
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $17,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225907
Policy instance 5
Insurance contract or identification number225907
Number of Individuals Covered63
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $14,870
Welfare Benefit Premiums Paid to CarrierUSD $403,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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