MURCOR, INC WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	MURCOR, INC WELFARE BENEFIT PLAN
Plan identification number	501

MURCOR, INC WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare 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

MURCOR, INC. has sponsored the creation of one or more 401k plans.

Company Name:	MURCOR, INC.
Employer identification number (EIN):	954072376
NAIC Classification:	522292
NAIC Description:	Real Estate Credit

Additional information about MURCOR, INC.

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2013-02-25
Company Identification Number:	0801741639
Legal Registered Office Address:	740 CORPORATE CENTER DR STE 100 POMONA United States of America (USA) 91768

More information about MURCOR, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MURCOR, INC WELFARE BENEFIT PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	MARYBETH SOSA
501	2016-01-01	MARYBETH SOSA
501	2015-01-01	MARYBETH SOSA
501	2014-01-01	MARYBETH SOSA
501	2013-01-01	MARYBETH SOSA
501	2012-01-01	MARYBETH SOSA
501	2011-11-01	MARYBETH SOSA
501	2010-11-01	MARYBETH SOSA
501	2010-02-01	MARYBETH SOSA
501	2009-02-01	MARYBETH SOSA

Plan Statistics for MURCOR, INC WELFARE BENEFIT PLAN

401k plan membership statisitcs for MURCOR, INC WELFARE BENEFIT PLAN

Measure	Date	Value
2022: MURCOR, INC WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	203
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	162
Total of all active and inactive participants	2022-01-01	162
2021: MURCOR, INC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	272
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	203
Total of all active and inactive participants	2021-01-01	203
2020: MURCOR, INC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	274
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	273
Number of retired or separated participants receiving benefits	2020-01-01	1
Total of all active and inactive participants	2020-01-01	274
2019: MURCOR, INC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	278
Number of retired or separated participants receiving benefits	2019-01-01	3
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	281
2018: MURCOR, INC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	304
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	277
Number of retired or separated participants receiving benefits	2018-01-01	11
Total of all active and inactive participants	2018-01-01	288
2017: MURCOR, INC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	326
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	261
Number of retired or separated participants receiving benefits	2017-01-01	64
Total of all active and inactive participants	2017-01-01	325
2016: MURCOR, INC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	415
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	316
Number of retired or separated participants receiving benefits	2016-01-01	10
Total of all active and inactive participants	2016-01-01	326
2015: MURCOR, INC WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	429
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	359
Number of retired or separated participants receiving benefits	2015-01-01	3
Total of all active and inactive participants	2015-01-01	362
2014: MURCOR, INC WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	428
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	429
Number of retired or separated participants receiving benefits	2014-01-01	8
Total of all active and inactive participants	2014-01-01	437
2013: MURCOR, INC WELFARE BENEFIT 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	420
Number of retired or separated participants receiving benefits	2013-01-01	5
Total of all active and inactive participants	2013-01-01	425
2012: MURCOR, INC WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	326
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	347
Number of retired or separated participants receiving benefits	2012-01-01	15
Total of all active and inactive participants	2012-01-01	362
2011: MURCOR, INC WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-11-01	330
Total number of active participants reported on line 7a of the Form 5500	2011-11-01	389
Number of retired or separated participants receiving benefits	2011-11-01	5
Total of all active and inactive participants	2011-11-01	394
2010: MURCOR, INC WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-11-01	451
Total number of active participants reported on line 7a of the Form 5500	2010-11-01	325
Number of retired or separated participants receiving benefits	2010-11-01	5
Total of all active and inactive participants	2010-11-01	330
Total participants, beginning-of-year	2010-02-01	349
Total number of active participants reported on line 7a of the Form 5500	2010-02-01	447
Number of retired or separated participants receiving benefits	2010-02-01	4
Number of other retired or separated participants entitled to future benefits	2010-02-01	0
Total of all active and inactive participants	2010-02-01	451
2009: MURCOR, INC WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-02-01	217
Total number of active participants reported on line 7a of the Form 5500	2009-02-01	345
Number of retired or separated participants receiving benefits	2009-02-01	4
Number of other retired or separated participants entitled to future benefits	2009-02-01	0
Total of all active and inactive participants	2009-02-01	349

Form 5500 Responses for MURCOR, INC WELFARE BENEFIT PLAN

2022: MURCOR, INC WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: MURCOR, INC WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: MURCOR, INC WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: MURCOR, INC WELFARE BENEFIT 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 benefit arrangement – Insurance	Yes
2018: MURCOR, INC WELFARE BENEFIT 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 benefit arrangement – Insurance	Yes
2017: MURCOR, INC WELFARE BENEFIT 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 benefit arrangement – Insurance	Yes
2016: MURCOR, INC WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: MURCOR, INC WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: MURCOR, INC WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: MURCOR, INC WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: MURCOR, INC WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: MURCOR, INC WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-11-01	Type of plan entity	Single employer plan
2011-11-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2011-11-01	Plan funding arrangement – Insurance	Yes
2011-11-01	Plan benefit arrangement – Insurance	Yes
2010: MURCOR, INC WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-11-01	Type of plan entity	Single employer plan
2010-11-01	Plan funding arrangement – Insurance	Yes
2010-11-01	Plan benefit arrangement – Insurance	Yes
2010-02-01	Type of plan entity	Single employer plan
2010-02-01	Submission has been amended	No
2010-02-01	This submission is the final filing	No
2010-02-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2010-02-01	Plan is a collectively bargained plan	No
2010-02-01	Plan funding arrangement – Insurance	Yes
2010-02-01	Plan benefit arrangement – Insurance	Yes
2009: MURCOR, INC WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-02-01	Type of plan entity	Single employer plan
2009-02-01	Submission has been amended	No
2009-02-01	This submission is the final filing	No
2009-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-02-01	Plan is a collectively bargained plan	No
2009-02-01	Plan funding arrangement – Insurance	Yes
2009-02-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	4
Insurance contract or identification number 30016249 Number of Individuals Covered 136 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,646 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $38,022 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,646 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	3336465
Policy instance	1
Insurance contract or identification number 3336465 Number of Individuals Covered 328 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $69,052 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit 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 PREPAID DENTAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $613,917 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $69,052 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961744
Policy instance	2
Insurance contract or identification number VDT961744 Number of Individuals Covered 30 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $4,793 Total amount of fees paid to insurance company USD $867 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $54,278 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,793 Amount paid for insurance broker fees 867 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961745
Policy instance	3
Insurance contract or identification number VDT961745 Number of Individuals Covered 31 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $3,490 Total amount of fees paid to insurance company USD $583 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $38,381 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,490 Amount paid for insurance broker fees 583 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD068088
Policy instance	5
Insurance contract or identification number NYD068088 Number of Individuals Covered 1 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $47 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 STATUTORY DISABILITY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $469 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 Insurance broker organization code? 3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD068088
Policy instance	6
Insurance contract or identification number NYD068088 Number of Individuals Covered 1 Insurance policy start date 2021-07-01 Insurance policy end date 2022-07-01 Total amount of commissions paid to insurance broker USD $12 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 STATUTORY DISABILITY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $118 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3620705
Policy instance	7
Insurance contract or identification number E3620705 Number of Individuals Covered 15 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,248 Total amount of fees paid to insurance company USD $88 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,585 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $464 Insurance broker organization code? 3 Amount paid for insurance broker fees 62 Additional information about fees paid to insurance broker FEES PAID
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4416194
Policy instance	8
Insurance contract or identification number E4416194 Number of Individuals Covered 2 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $224 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 VOLUNTARY SUPPLEMENTAL BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,319 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $93 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3648979
Policy instance	9
Insurance contract or identification number E3648979 Number of Individuals Covered 6 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $147 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 VOLUNTARY SUPPLEMENTAL BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,708 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $58 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 967943
Policy instance	14
Insurance contract or identification number OK 967943 Number of Individuals Covered 84 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $685 Total amount of fees paid to insurance company USD $82 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,047 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $685 Amount paid for insurance broker fees 82 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966413
Policy instance	13
Insurance contract or identification number FLX966413 Number of Individuals Covered 84 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $9,555 Total amount of fees paid to insurance company USD $993 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $69,147 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,555 Amount paid for insurance broker fees 993 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090536
Policy instance	12
Insurance contract or identification number 6090536 Number of Individuals Covered 39 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $995 Total amount of fees paid to insurance company USD $247 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $10,043 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $995 Insurance broker organization code? 3 Amount paid for insurance broker fees 175 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number
Policy instance	11
Number of Individuals Covered 152 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,471 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231466
Policy instance	10
Insurance contract or identification number 231466 Number of Individuals Covered 92 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $22,056 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $623,672 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,056 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	3336465
Policy instance	1
Insurance contract or identification number 3336465 Number of Individuals Covered 385 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $81,462 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit 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 PREPAID DENTAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $726,813 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $81,462 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961744
Policy instance	2
Insurance contract or identification number VDT961744 Number of Individuals Covered 35 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $7,178 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $71,779 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,178 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961745
Policy instance	3
Insurance contract or identification number VDT961745 Number of Individuals Covered 34 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $4,808 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $48,076 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,808 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	4
Insurance contract or identification number 30016249 Number of Individuals Covered 164 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,727 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $44,960 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,727 Insurance broker organization code? 3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD068088
Policy instance	5
Insurance contract or identification number NYD068088 Number of Individuals Covered 1 Insurance policy start date 2021-02-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $2 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 STATUTORY DISABILITY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2 Insurance broker organization code? 3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD068088
Policy instance	6
Insurance contract or identification number NYD068088 Number of Individuals Covered 1 Insurance policy start date 2020-07-01 Insurance policy end date 2021-07-01 Total amount of commissions paid to insurance broker USD $26 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 STATUTORY DISABILITY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $264 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $26 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4416194
Policy instance	8
Insurance contract or identification number E4416194 Number of Individuals Covered 3 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $447 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 VOLUNTARY SUPPLEMENTAL BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,643 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $163 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3648979
Policy instance	9
Insurance contract or identification number E3648979 Number of Individuals Covered 4 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $165 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 VOLUNTARY SUPPLEMENTAL BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,537 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 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3620705
Policy instance	7
Insurance contract or identification number E3620705 Number of Individuals Covered 18 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $941 Total amount of fees paid to insurance company USD $6 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,834 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $325 Insurance broker organization code? 3 Amount paid for insurance broker fees 4 Additional information about fees paid to insurance broker FEES PAID
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 967943
Policy instance	14
Insurance contract or identification number OK 967943 Number of Individuals Covered 111 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,007 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,713 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,007 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966413
Policy instance	13
Insurance contract or identification number FLX966413 Number of Individuals Covered 111 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $11,962 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $79,745 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,962 Insurance broker organization code? 3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090536
Policy instance	12
Insurance contract or identification number 6090536 Number of Individuals Covered 37 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,229 Total amount of fees paid to insurance company USD $166 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,480 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,229 Insurance broker organization code? 3 Amount paid for insurance broker fees 166 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231466
Policy instance	10
Insurance contract or identification number 231466 Number of Individuals Covered 121 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $25,556 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $681,872 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,556 Insurance broker organization code? 3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number
Policy instance	11
Number of Individuals Covered 187 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,506 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	3
Insurance contract or identification number 30016249 Number of Individuals Covered 222 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,883 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $51,235 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,883 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3620705
Policy instance	4
Insurance contract or identification number E3620705 Number of Individuals Covered 20 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $2,511 Total amount of fees paid to insurance company USD $337 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $19,927 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $780 Amount paid for insurance broker fees 227 Additional information about fees paid to insurance broker FEES PAID Insurance broker organization code? 3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number
Policy instance	2
Number of Individuals Covered 270 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 $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $5,222 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961745
Policy instance	11
Insurance contract or identification number VDT961745 Number of Individuals Covered 103 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $6,048 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $60,479 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,048 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3648979
Policy instance	5
Insurance contract or identification number E3648979 Number of Individuals Covered 7 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $274 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $5,334 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $90 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231466
Policy instance	6
Insurance contract or identification number 231466 Number of Individuals Covered 128 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $25,847 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $736,550 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,847 Insurance broker organization code? 3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090536
Policy instance	7
Insurance contract or identification number 6090536 Number of Individuals Covered 65 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,507 Total amount of fees paid to insurance company USD $157 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $14,411 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,507 Amount paid for insurance broker fees 157 Additional information about fees paid to insurance broker NON-MONETARY AND SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4416194
Policy instance	8
Insurance contract or identification number E4416194 Number of Individuals Covered 3 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,695 Total amount of fees paid to insurance company USD $240 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $9,076 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $596 Amount paid for insurance broker fees 165 Additional information about fees paid to insurance broker FEES PAID Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966413
Policy instance	9
Insurance contract or identification number FLX966413 Number of Individuals Covered 529 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $13,220 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $88,135 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,220 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961744
Policy instance	10
Insurance contract or identification number VDT961744 Number of Individuals Covered 115 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $9,736 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $97,361 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,736 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 967943
Policy instance	12
Insurance contract or identification number OK 967943 Number of Individuals Covered 529 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,284 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $8,559 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,284 Insurance broker organization code? 3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD068088
Policy instance	13
Insurance contract or identification number NYD068088 Number of Individuals Covered 1 Insurance policy start date 2019-07-01 Insurance policy end date 2020-07-01 Total amount of commissions paid to insurance broker USD $19 Total amount of fees paid to insurance company USD $2 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $189 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19 Amount paid for insurance broker fees 2 Additional information about fees paid to insurance broker OVERRIDE FEES PAID 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	3336465
Policy instance	1
Insurance contract or identification number 3336465 Number of Individuals Covered 509 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $92,908 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $738,802 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $92,908 Insurance broker organization code? 3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD068088
Policy instance	13
Insurance contract or identification number NYD068088 Number of Individuals Covered 1 Insurance policy start date 2018-07-01 Insurance policy end date 2019-07-01 Total amount of commissions paid to insurance broker USD $7 Total amount of fees paid to insurance company USD $1 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $69 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7 Amount paid for insurance broker fees 1 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number
Policy instance	2
Number of Individuals Covered 279 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $5,225 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 number	E3620705
Policy instance	4
Insurance contract or identification number E3620705 Number of Individuals Covered 25 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $2,273 Total amount of fees paid to insurance company USD $216 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $19,111 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $721 Insurance broker organization code? 3 Amount paid for insurance broker fees 154 Additional information about fees paid to insurance broker FEES PAID
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3648979
Policy instance	5
Insurance contract or identification number E3648979 Number of Individuals Covered 10 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $663 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $9,500 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $218 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231466
Policy instance	6
Insurance contract or identification number 231466 Number of Individuals Covered 133 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $21,392 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $631,481 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,392 Insurance broker organization code? 3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090536
Policy instance	7
Insurance contract or identification number 6090536 Number of Individuals Covered 59 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,537 Total amount of fees paid to insurance company USD $111 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $14,664 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,537 Amount paid for insurance broker fees 111 Additional information about fees paid to insurance broker SUPPLEMENTAL AND NON-MONETARY COMPENSATION Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4416194
Policy instance	8
Insurance contract or identification number E4416194 Number of Individuals Covered 9 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $2,357 Total amount of fees paid to insurance company USD $422 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $10,559 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $846 Amount paid for insurance broker fees 300 Additional information about fees paid to insurance broker FEES PAID Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966413
Policy instance	9
Insurance contract or identification number FLX966413 Number of Individuals Covered 554 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $10,005 Total amount of fees paid to insurance company USD $1,048 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $66,699 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,005 Amount paid for insurance broker fees 1048 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961744
Policy instance	10
Insurance contract or identification number VDT961744 Number of Individuals Covered 123 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $7,782 Total amount of fees paid to insurance company USD $1,291 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $77,824 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,782 Amount paid for insurance broker fees 1291 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961745
Policy instance	11
Insurance contract or identification number VDT961745 Number of Individuals Covered 108 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $4,504 Total amount of fees paid to insurance company USD $728 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $45,043 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,504 Amount paid for insurance broker fees 728 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 967943
Policy instance	12
Insurance contract or identification number OK 967943 Number of Individuals Covered 553 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,085 Total amount of fees paid to insurance company USD $126 Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $7,233 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,085 Amount paid for insurance broker fees 126 Additional information about fees paid to insurance broker OVERRIDE 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	3336465
Policy instance	1
Insurance contract or identification number 3336465 Number of Individuals Covered 526 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $71,881 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $746,883 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $71,881 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	3
Insurance contract or identification number 30016249 Number of Individuals Covered 224 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,779 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $52,375 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,779 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	3336465
Policy instance	1
Insurance contract or identification number 3336465 Number of Individuals Covered 585 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $90,193 Total amount of fees paid to insurance company USD $686 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $802,011 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $90,193 Amount paid for insurance broker fees 686 Additional information about fees paid to insurance broker SERVICE/GEN AGENT FEES Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number
Policy instance	2
Number of Individuals Covered 318 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $6,413 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	3
Insurance contract or identification number 30016249 Number of Individuals Covered 246 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,848 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $61,238 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,848 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES LLC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3620705
Policy instance	4
Insurance contract or identification number E3620705 Number of Individuals Covered 22 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,946 Total amount of fees paid to insurance company USD $337 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $21,261 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $885 Insurance broker organization code? 3 Amount paid for insurance broker fees 172 Additional information about fees paid to insurance broker FEES PAID Insurance broker name JACK WU
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231466
Policy instance	6
Insurance contract or identification number 231466 Number of Individuals Covered 167 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $24,514 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $686,791 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,514 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3648979
Policy instance	5
Insurance contract or identification number E3648979 Number of Individuals Covered 16 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,230 Total amount of fees paid to insurance company USD $16 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $14,928 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $324 Insurance broker organization code? 3 Amount paid for insurance broker fees 3 Insurance broker name MAUREEN E CONRAN
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090536
Policy instance	7
Insurance contract or identification number 6090536 Number of Individuals Covered 94 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,122 Total amount of fees paid to insurance company USD $426 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $20,456 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,122 Amount paid for insurance broker fees 426 Additional information about fees paid to insurance broker NON-MONETARY AND SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4416194
Policy instance	8
Insurance contract or identification number E4416194 Number of Individuals Covered 5 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,317 Total amount of fees paid to insurance company USD $181 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $6,823 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $474 Insurance broker organization code? 3 Amount paid for insurance broker fees 88 Insurance broker name BENEFITS BY DESIGN INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966413
Policy instance	9
Insurance contract or identification number FLX966413 Number of Individuals Covered 161 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $11,022 Total amount of fees paid to insurance company USD $1,863 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $73,483 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,022 Amount paid for insurance broker fees 2185 Additional information about fees paid to insurance broker SALES & SERVICE AND OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name C2 CENTRIC LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961744
Policy instance	10
Insurance contract or identification number VDT961744 Number of Individuals Covered 81 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $10,115 Total amount of fees paid to insurance company USD $2,598 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $101,146 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,115 Amount paid for insurance broker fees 3043 Additional information about fees paid to insurance broker SALES & SERVICE AND OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name C2 CENTRIC LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961745
Policy instance	11
Insurance contract or identification number VDT961745 Number of Individuals Covered 65 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $5,983 Total amount of fees paid to insurance company USD $1,400 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $59,826 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,983 Amount paid for insurance broker fees 1667 Additional information about fees paid to insurance broker SALES & SERVICE AND OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name C2 CENTRIC LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 967943
Policy instance	12
Insurance contract or identification number OK 967943 Number of Individuals Covered 161 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,380 Total amount of fees paid to insurance company USD $238 Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $9,198 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,380 Amount paid for insurance broker fees 278 Additional information about fees paid to insurance broker SALES & SERVICE AND OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name C2 CENTRIC LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD068088
Policy instance	13
Insurance contract or identification number NYD068088 Insurance policy start date 2016-07-01 Insurance policy end date 2017-07-01 Total amount of commissions paid to insurance broker USD $16 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $163 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3648979
Policy instance	5
Insurance contract or identification number E3648979 Number of Individuals Covered 26 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $4,251 Total amount of fees paid to insurance company USD $489 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $22,948 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,227 Insurance broker organization code? 3 Amount paid for insurance broker fees 254 Additional information about fees paid to insurance broker OTHER FEES PAID Insurance broker name JACK WU
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 967943
Policy instance	12
Insurance contract or identification number OK 967943 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $1,636 Total amount of fees paid to insurance company USD $670 Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $10,907 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,636 Amount paid for insurance broker fees 670 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	3
Insurance contract or identification number 30016249 Number of Individuals Covered 302 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $2,155 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $73,016 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,155 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number
Policy instance	2
Number of Individuals Covered 332 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $6,724 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3336465
Policy instance	1
Insurance contract or identification number 3336465 Number of Individuals Covered 717 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $109,431 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $771,839 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $109,431 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231466
Policy instance	6
Insurance contract or identification number 231466 Number of Individuals Covered 169 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $23,657 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $677,011 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,657 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090536
Policy instance	7
Insurance contract or identification number 6090536 Number of Individuals Covered 84 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $2,207 Total amount of fees paid to insurance company USD $418 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $21,957 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,207 Amount paid for insurance broker fees 418 Additional information about fees paid to insurance broker SUPPLEMENTAL AND NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4416194
Policy instance	8
Insurance contract or identification number E4416194 Number of Individuals Covered 1 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $334 Total amount of fees paid to insurance company USD $51 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $754 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $156 Insurance broker organization code? 3 Amount paid for insurance broker fees 18 Additional information about fees paid to insurance broker OTHER FEES PAID Insurance broker name PATRICK IAN WAGNER
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3620705
Policy instance	4
Insurance contract or identification number E3620705 Number of Individuals Covered 25 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $6,227 Total amount of fees paid to insurance company USD $614 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $32,239 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,032 Insurance broker organization code? 3 Amount paid for insurance broker fees 168 Additional information about fees paid to insurance broker OTHER FEES PAID Insurance broker name LAMBERT MONTALBO
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966413
Policy instance	9
Insurance contract or identification number FLX966413 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $11,960 Total amount of fees paid to insurance company USD $5,228 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $84,220 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,960 Amount paid for insurance broker fees 5228 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961744
Policy instance	10
Insurance contract or identification number VDT961744 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $10,241 Total amount of fees paid to insurance company USD $6,196 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $102,413 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,241 Amount paid for insurance broker fees 6196 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961745
Policy instance	11
Insurance contract or identification number VDT961745 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $5,994 Total amount of fees paid to insurance company USD $3,481 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $59,938 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,994 Amount paid for insurance broker fees 3481 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3336465
Policy instance	1
Insurance contract or identification number 3336465 Number of Individuals Covered 364 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $6,615 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $332,952 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,615 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AGDD
Policy instance	9
Insurance contract or identification number GVTL0AGDD Number of Individuals Covered 242 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $7,925 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $79,248 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,925 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AGDD
Policy instance	8
Insurance contract or identification number GLTD0AGDD Number of Individuals Covered 39 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $1,620 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $16,200 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,620 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AGDD
Policy instance	11
Insurance contract or identification number GLUG0AGDD Number of Individuals Covered 435 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $2,947 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $19,648 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,947 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3648979
Policy instance	10
Insurance contract or identification number E3648979 Number of Individuals Covered 33 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $4,643 Total amount of fees paid to insurance company USD $496 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $24,767 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,341 Amount paid for insurance broker fees 33 Additional information about fees paid to insurance broker OTHER FEES PAID Insurance broker organization code? 3 Insurance broker name MARY BETH HARRIS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG 0AGDD
Policy instance	7
Insurance contract or identification number GUG 0AGDD Number of Individuals Covered 39 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $563 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,634 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $563 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3620705
Policy instance	6
Insurance contract or identification number E3620705 Number of Individuals Covered 34 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $6,402 Total amount of fees paid to insurance company USD $986 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $34,286 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,113 Amount paid for insurance broker fees 53 Additional information about fees paid to insurance broker OTHER FEES PAID Insurance broker organization code? 3 Insurance broker name PATRICK IAN WAGNER
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231466
Policy instance	12
Insurance contract or identification number 231466 Number of Individuals Covered 195 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $25,433 Total amount of fees paid to insurance company USD $5,425 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $723,853 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,433 Amount paid for insurance broker fees 5425 Additional information about fees paid to insurance broker BONUS AMOUNT Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC OAGDD
Policy instance	4
Insurance contract or identification number GUC OAGDD Number of Individuals Covered 140 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $10,592 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $105,918 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,592 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	3
Insurance contract or identification number 30016249 Number of Individuals Covered 355 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $2,258 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $80,994 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,258 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number
Policy instance	2
Number of Individuals Covered 425 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $7,946 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	753008
Policy instance	13
Insurance contract or identification number 753008 Number of Individuals Covered 609 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $110,052 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,948,606 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 110052 Additional information about fees paid to insurance broker SERVICE FEE AGREEMENT AND BONUS FEES Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090536
Policy instance	14
Insurance contract or identification number 6090536 Number of Individuals Covered 95 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $2,223 Total amount of fees paid to insurance company USD $501 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $22,484 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,223 Amount paid for insurance broker fees 501 Additional information about fees paid to insurance broker SUPPLEMENTAL AND NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AGDD
Policy instance	5
Insurance contract or identification number GUPR0AGDD Number of Individuals Covered 129 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $4,776 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $47,762 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,776 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AGDD
Policy instance	13
Insurance contract or identification number GLUG0AGDD Number of Individuals Covered 374 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $2,489 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $16,591 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,489 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	3
Insurance contract or identification number 30016249 Number of Individuals Covered 353 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $2,531 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $96,112 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,531 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	275370
Policy instance	4
Insurance contract or identification number 275370 Number of Individuals Covered 0 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $405 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $299 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $405 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275370
Policy instance	5
Insurance contract or identification number 275370 Number of Individuals Covered 0 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $12,251 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $9,033 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,251 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC OAGDD
Policy instance	6
Insurance contract or identification number GUC OAGDD Number of Individuals Covered 117 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $9,380 Total amount of fees paid to insurance company USD $2,336 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $93,804 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,380 Amount paid for insurance broker fees 2336 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3620705
Policy instance	8
Insurance contract or identification number E3620705 Number of Individuals Covered 43 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $7,424 Total amount of fees paid to insurance company USD $1,827 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $41,521 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,117 Amount paid for insurance broker fees 332 Additional information about fees paid to insurance broker OTHER FEES PAID Insurance broker organization code? 3 Insurance broker name ASCENSION BENEFIT ADVISORS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG 0AGDD
Policy instance	9
Insurance contract or identification number GUG 0AGDD Number of Individuals Covered 14 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $468 Total amount of fees paid to insurance company USD $111 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,674 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $468 Amount paid for insurance broker fees 111 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AGDD
Policy instance	10
Insurance contract or identification number GLTD0AGDD Number of Individuals Covered 33 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $1,315 Total amount of fees paid to insurance company USD $322 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,145 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,315 Amount paid for insurance broker fees 322 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AGDD
Policy instance	11
Insurance contract or identification number GVTL0AGDD Number of Individuals Covered 216 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $7,963 Total amount of fees paid to insurance company USD $1,813 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $79,628 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,963 Amount paid for insurance broker fees 1813 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3648979
Policy instance	12
Insurance contract or identification number E3648979 Number of Individuals Covered 36 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $2,210 Total amount of fees paid to insurance company USD $243 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $23,925 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $926 Insurance broker organization code? 3 Amount paid for insurance broker fees 122 Additional information about fees paid to insurance broker OTHER FEES PAID Insurance broker name CAPSTONE BENEFIT SOLUTIONS LLC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	231466
Policy instance	14
Insurance contract or identification number 231466 Number of Individuals Covered 210 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $22,181 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $639,860 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,181 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	6090536
Policy instance	16
Insurance contract or identification number 6090536 Number of Individuals Covered 82 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $1,975 Total amount of fees paid to insurance company USD $654 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $18,213 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,975 Amount paid for insurance broker fees 654 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number
Policy instance	2
Number of Individuals Covered 398 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $7,763 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3336465
Policy instance	1
Insurance contract or identification number 3336465 Number of Individuals Covered 367 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $7,757 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $390,371 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,757 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AGDD
Policy instance	7
Insurance contract or identification number GUPR0AGDD Number of Individuals Covered 122 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $4,909 Total amount of fees paid to insurance company USD $1,169 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $49,097 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,909 Amount paid for insurance broker fees 1169 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	753008
Policy instance	15
Insurance contract or identification number 753008 Number of Individuals Covered 682 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $106,743 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,598,683 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $106,743 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AGDD
Policy instance	10
Insurance contract or identification number GLTD0AGDD Number of Individuals Covered 31 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $1,382 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,824 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,382 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	3
Insurance contract or identification number 30016249 Number of Individuals Covered 348 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $2,565 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $101,003 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,565 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	275370
Policy instance	4
Insurance contract or identification number 275370 Number of Individuals Covered 91 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $18,978 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $594,309 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,978 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275370
Policy instance	5
Insurance contract or identification number 275370 Number of Individuals Covered 290 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $114,802 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,595,082 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $114,802 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC OAGDD
Policy instance	6
Insurance contract or identification number GUC OAGDD Number of Individuals Covered 122 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $10,309 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $103,094 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,309 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3648979
Policy instance	12
Insurance contract or identification number E3648979 Number of Individuals Covered 42 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $4,343 Total amount of fees paid to insurance company USD $582 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $34,512 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,534 Amount paid for insurance broker fees 82 Additional information about fees paid to insurance broker OTHER FEES PAID Insurance broker organization code? 3 Insurance broker name COLONIAL OF NORTH TEXAS INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AGDD
Policy instance	11
Insurance contract or identification number GVTL0AGDD Number of Individuals Covered 218 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $8,332 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $83,324 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,332 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AGDD
Policy instance	7
Insurance contract or identification number GUPR0AGDD Number of Individuals Covered 128 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $5,113 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $51,132 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,113 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG 0AGDD
Policy instance	9
Insurance contract or identification number GUG 0AGDD Number of Individuals Covered 14 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $477 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,774 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $477 Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )
Policy contract number	27057
Policy instance	2
Insurance contract or identification number 27057 Number of Individuals Covered 432 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $10,851 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 number	E3620705
Policy instance	8
Insurance contract or identification number E3620705 Number of Individuals Covered 44 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $7,837 Total amount of fees paid to insurance company USD $1,465 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $36,962 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,085 Amount paid for insurance broker fees 699 Additional information about fees paid to insurance broker OTHER FEES PAID Insurance broker organization code? 3 Insurance broker name ASCENSION BENEFIT ADVISORS
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00451856
Policy instance	1
Insurance contract or identification number 00451856 Number of Individuals Covered 94 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $1,622 Total amount of fees paid to insurance company USD $6,374 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,295 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,622 Amount paid for insurance broker fees 6374 Additional information about fees paid to insurance broker OTHER FEES PAID Insurance broker organization code? 3 Insurance broker name HOLMES MURPHY AND ASSOCIATES, INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00451856
Policy instance	1
Insurance contract or identification number 00451856 Number of Individuals Covered 420 Insurance policy start date 2011-11-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $3,115 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $74,316 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )
Policy contract number	27057
Policy instance	2
Insurance contract or identification number 27057 Number of Individuals Covered 489 Insurance policy start date 2011-11-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $102 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $2,035 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	3
Insurance contract or identification number 30016249 Number of Individuals Covered 395 Insurance policy start date 2011-11-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $1,039 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,115 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	275370
Policy instance	4
Insurance contract or identification number 275370 Number of Individuals Covered 32 Insurance policy start date 2011-11-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $3,939 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $106,880 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 number	GUPR0AGDD
Policy instance	7
Insurance contract or identification number GUPR0AGDD Number of Individuals Covered 100 Insurance policy start date 2011-11-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $702 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,016 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 number	E3620705
Policy instance	8
Insurance contract or identification number E3620705 Number of Individuals Covered 44 Insurance policy start date 2011-11-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $1,674 Total amount of fees paid to insurance company USD $235 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $35,712 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 number	GUG 0AGDD
Policy instance	9
Insurance contract or identification number GUG 0AGDD Number of Individuals Covered 45 Insurance policy start date 2011-11-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $92 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $923 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 number	GLTD0AGDD
Policy instance	10
Insurance contract or identification number GLTD0AGDD Number of Individuals Covered 45 Insurance policy start date 2011-11-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $267 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,666 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275370
Policy instance	5
Insurance contract or identification number 275370 Number of Individuals Covered 319 Insurance policy start date 2011-11-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $23,608 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $640,565 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 number	GUC OAGDD
Policy instance	6
Insurance contract or identification number GUC OAGDD Number of Individuals Covered 124 Insurance policy start date 2011-11-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $1,889 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,890 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275370
Policy instance	5
Insurance contract or identification number 275370 Number of Individuals Covered 330 Insurance policy start date 2010-11-01 Insurance policy end date 2011-10-31 Total amount of commissions paid to insurance broker USD $170,721 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $3,713,200 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 number	GUPR0AGDD
Policy instance	7
Insurance contract or identification number GUPR0AGDD Number of Individuals Covered 106 Insurance policy start date 2010-11-01 Insurance policy end date 2011-10-31 Total amount of commissions paid to insurance broker USD $5,001 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $38,493 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00451856
Policy instance	1
Insurance contract or identification number 00451856 Number of Individuals Covered 433 Insurance policy start date 2010-11-01 Insurance policy end date 2011-10-31 Total amount of commissions paid to insurance broker USD $7,512 Total amount of fees paid to insurance company USD $11,786 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $367,479 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )
Policy contract number	27057
Policy instance	2
Insurance contract or identification number 27057 Number of Individuals Covered 505 Insurance policy start date 2010-11-01 Insurance policy end date 2011-10-31 Total amount of commissions paid to insurance broker USD $599 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $12,403 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	3
Insurance contract or identification number 30016249 Number of Individuals Covered 405 Insurance policy start date 2010-11-01 Insurance policy end date 2011-10-31 Total amount of commissions paid to insurance broker USD $4,912 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $109,816 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 number	E3620705
Policy instance	8
Insurance contract or identification number E3620705 Number of Individuals Covered 48 Insurance policy start date 2010-11-01 Insurance policy end date 2011-10-31 Total amount of commissions paid to insurance broker USD $15,900 Total amount of fees paid to insurance company USD $5,540 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided VOLUNTARY SUPPLEMENTAL BENEFITS Welfare Benefit Premiums Paid to Carrier USD $33,549 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	275370
Policy instance	4
Insurance contract or identification number 275370 Number of Individuals Covered 102 Insurance policy start date 2010-11-01 Insurance policy end date 2011-10-31 Total amount of commissions paid to insurance broker USD $31,395 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $682,840 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 number	GUC OAGDD
Policy instance	6
Insurance contract or identification number GUC OAGDD Number of Individuals Covered 137 Insurance policy start date 2010-11-01 Insurance policy end date 2011-10-31 Total amount of commissions paid to insurance broker USD $12,082 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $105,160 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00451856
Policy instance	1
Insurance contract or identification number 00451856 Number of Individuals Covered 364 Insurance policy start date 2009-11-01 Insurance policy end date 2010-10-31 Total amount of commissions paid to insurance broker USD $6,003 Total amount of fees paid to insurance company USD $373 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $266,891 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,003 Amount paid for insurance broker fees 373 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name ANDREINI & COMPANY
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275370
Policy instance	5
Insurance contract or identification number 275370 Number of Individuals Covered 361 Insurance policy start date 2009-11-01 Insurance policy end date 2010-10-31 Total amount of commissions paid to insurance broker USD $2,833 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $61,318 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,833 Insurance broker organization code? 3 Insurance broker name ANDREINI & COMPANY
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30016249
Policy instance	4
Insurance contract or identification number 30016249 Number of Individuals Covered 363 Insurance policy start date 2009-11-01 Insurance policy end date 2010-10-31 Total amount of commissions paid to insurance broker USD $2,420 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $88,367 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,420 Insurance broker organization code? 3 Insurance broker name ANDREINI & COMPANY
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	275370
Policy instance	3
Insurance contract or identification number 275370 Number of Individuals Covered 361 Insurance policy start date 2009-11-01 Insurance policy end date 2010-10-31 Total amount of commissions paid to insurance broker USD $144,869 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,135,299 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $144,869 Insurance broker organization code? 3 Insurance broker name ANDREINI & COMPANY
HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )
Policy contract number	27057
Policy instance	2
Insurance contract or identification number 27057 Number of Individuals Covered 447 Insurance policy start date 2009-11-01 Insurance policy end date 2010-10-31 Total amount of commissions paid to insurance broker USD $457 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,141 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $457 Insurance broker organization code? 3 Insurance broker name ANDREINI & COMPANY