SKECHERS USA, INC. has sponsored the creation of one or more 401k plans.
Measure | Date | Value |
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2022: SKECHERS WELFARE BENEFIT PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 2,285 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 3,252 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 41 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 3,293 |
Number of employers contributing to the scheme | 2022-01-01 | 0 |
2021: SKECHERS WELFARE BENEFIT PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-01-01 | 2,216 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 2,264 |
Number of retired or separated participants receiving benefits | 2021-01-01 | 21 |
Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
Total of all active and inactive participants | 2021-01-01 | 2,285 |
Number of employers contributing to the scheme | 2021-01-01 | 0 |
2020: SKECHERS WELFARE BENEFIT PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 2,010 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 1,882 |
Number of retired or separated participants receiving benefits | 2020-01-01 | 36 |
Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 3 |
Total of all active and inactive participants | 2020-01-01 | 1,921 |
Number of employers contributing to the scheme | 2020-01-01 | 0 |
2019: SKECHERS WELFARE BENEFIT PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-01-01 | 1,890 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 1,901 |
Number of retired or separated participants receiving benefits | 2019-01-01 | 31 |
Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 78 |
Total of all active and inactive participants | 2019-01-01 | 2,010 |
Number of employers contributing to the scheme | 2019-01-01 | 0 |
2018: SKECHERS WELFARE BENEFIT PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-01-01 | 1,695 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 1,819 |
Number of retired or separated participants receiving benefits | 2018-01-01 | 21 |
Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 50 |
Total of all active and inactive participants | 2018-01-01 | 1,890 |
Number of employers contributing to the scheme | 2018-01-01 | 0 |
2017: SKECHERS WELFARE BENEFIT PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-01-01 | 1,772 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 1,606 |
Number of retired or separated participants receiving benefits | 2017-01-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 84 |
Total of all active and inactive participants | 2017-01-01 | 1,695 |
2016: SKECHERS WELFARE BENEFIT PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-01-01 | 1,539 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 1,501 |
Number of retired or separated participants receiving benefits | 2016-01-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 102 |
Total of all active and inactive participants | 2016-01-01 | 1,608 |
2015: SKECHERS WELFARE BENEFIT PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-01-01 | 1,386 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 1,477 |
Number of retired or separated participants receiving benefits | 2015-01-01 | 8 |
Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 54 |
Total of all active and inactive participants | 2015-01-01 | 1,539 |
2014: SKECHERS WELFARE BENEFIT PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-01-01 | 1,272 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 1,375 |
Number of retired or separated participants receiving benefits | 2014-01-01 | 11 |
Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 30 |
Total of all active and inactive participants | 2014-01-01 | 1,416 |
2013: SKECHERS WELFARE BENEFIT PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-01-01 | 1,146 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 1,209 |
Number of retired or separated participants receiving benefits | 2013-01-01 | 9 |
Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 54 |
Total of all active and inactive participants | 2013-01-01 | 1,272 |
2012: SKECHERS WELFARE BENEFIT PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-01-01 | 1,142 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 1,135 |
Number of retired or separated participants receiving benefits | 2012-01-01 | 11 |
Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
Total of all active and inactive participants | 2012-01-01 | 1,146 |
2011: SKECHERS WELFARE BENEFIT PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-01-01 | 1,160 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 1,236 |
Number of retired or separated participants receiving benefits | 2011-01-01 | 20 |
Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
Total of all active and inactive participants | 2011-01-01 | 1,256 |
2009: SKECHERS WELFARE BENEFIT PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-01-01 | 1,127 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 1,072 |
Number of retired or separated participants receiving benefits | 2009-01-01 | 32 |
Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
Total of all active and inactive participants | 2009-01-01 | 1,104 |
2022: SKECHERS WELFARE BENEFIT PLAN 2022 form 5500 responses |
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2022-01-01 | Type of plan entity | Single employer plan |
2022-01-01 | Plan funding arrangement – Insurance | Yes |
2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-01-01 | Plan benefit arrangement – Insurance | Yes |
2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: SKECHERS WELFARE BENEFIT PLAN 2021 form 5500 responses |
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2021-01-01 | Type of plan entity | Single employer plan |
2021-01-01 | Plan funding arrangement – Insurance | Yes |
2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-01-01 | Plan benefit arrangement – Insurance | Yes |
2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: SKECHERS WELFARE BENEFIT PLAN 2020 form 5500 responses |
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2020-01-01 | Type of plan entity | Single employer plan |
2020-01-01 | Plan funding arrangement – Insurance | Yes |
2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-01-01 | Plan benefit arrangement – Insurance | Yes |
2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: SKECHERS WELFARE BENEFIT PLAN 2019 form 5500 responses |
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2019-01-01 | Type of plan entity | Single employer plan |
2019-01-01 | Plan funding arrangement – Insurance | Yes |
2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-01-01 | Plan benefit arrangement – Insurance | Yes |
2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: SKECHERS WELFARE BENEFIT PLAN 2018 form 5500 responses |
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2018-01-01 | Type of plan entity | Single employer plan |
2018-01-01 | Plan funding arrangement – Insurance | Yes |
2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-01-01 | Plan benefit arrangement – Insurance | Yes |
2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2017: SKECHERS WELFARE BENEFIT PLAN 2017 form 5500 responses |
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2017-01-01 | Type of plan entity | Single employer plan |
2017-01-01 | Plan funding arrangement – Insurance | Yes |
2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-01-01 | Plan benefit arrangement – Insurance | Yes |
2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2016: SKECHERS WELFARE BENEFIT PLAN 2016 form 5500 responses |
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2016-01-01 | Type of plan entity | Single employer plan |
2016-01-01 | Submission has been amended | No |
2016-01-01 | This submission is the final filing | No |
2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-01-01 | Plan is a collectively bargained plan | No |
2016-01-01 | Plan funding arrangement – Insurance | Yes |
2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2016-01-01 | Plan benefit arrangement – Insurance | Yes |
2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2015: SKECHERS WELFARE BENEFIT PLAN 2015 form 5500 responses |
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2015-01-01 | Type of plan entity | Single employer plan |
2015-01-01 | Submission has been amended | No |
2015-01-01 | This submission is the final filing | No |
2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-01-01 | Plan is a collectively bargained plan | No |
2015-01-01 | Plan funding arrangement – Insurance | Yes |
2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2015-01-01 | Plan benefit arrangement – Insurance | Yes |
2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2014: SKECHERS WELFARE BENEFIT PLAN 2014 form 5500 responses |
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2014-01-01 | Type of plan entity | Single employer plan |
2014-01-01 | Submission has been amended | No |
2014-01-01 | This submission is the final filing | No |
2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-01-01 | Plan is a collectively bargained plan | No |
2014-01-01 | Plan funding arrangement – Insurance | Yes |
2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2014-01-01 | Plan benefit arrangement – Insurance | Yes |
2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2013: SKECHERS WELFARE BENEFIT PLAN 2013 form 5500 responses |
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2013-01-01 | Type of plan entity | Single employer plan |
2013-01-01 | Submission has been amended | No |
2013-01-01 | This submission is the final filing | No |
2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-01-01 | Plan is a collectively bargained plan | No |
2013-01-01 | Plan funding arrangement – Insurance | Yes |
2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2013-01-01 | Plan benefit arrangement – Insurance | Yes |
2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2012: SKECHERS WELFARE BENEFIT PLAN 2012 form 5500 responses |
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2012-01-01 | Type of plan entity | Single employer plan |
2012-01-01 | Submission has been amended | No |
2012-01-01 | This submission is the final filing | No |
2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-01-01 | Plan is a collectively bargained plan | No |
2012-01-01 | Plan funding arrangement – Insurance | Yes |
2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2012-01-01 | Plan benefit arrangement – Insurance | Yes |
2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2011: SKECHERS WELFARE BENEFIT PLAN 2011 form 5500 responses |
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2011-01-01 | Type of plan entity | Single employer plan |
2011-01-01 | Submission has been amended | No |
2011-01-01 | This submission is the final filing | No |
2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-01-01 | Plan is a collectively bargained plan | No |
2011-01-01 | Plan funding arrangement – Insurance | Yes |
2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2011-01-01 | Plan benefit arrangement – Insurance | Yes |
2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2009: SKECHERS WELFARE BENEFIT PLAN 2009 form 5500 responses |
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2009-01-01 | Type of plan entity | Single employer plan |
2009-01-01 | Submission has been amended | No |
2009-01-01 | This submission is the final filing | No |
2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2009-01-01 | Plan is a collectively bargained plan | No |
2009-01-01 | Plan funding arrangement – Insurance | Yes |
2009-01-01 | Plan benefit arrangement – Insurance | Yes |
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 2 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 38 | 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 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $256,354 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | GL163098 |
Policy instance | 6 |
Insurance contract or identification number | GL163098 | Number of Individuals Covered | 3252 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $54,353 | Total amount of fees paid to insurance company | USD $49,433 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $1,058,195 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $54,353 | Amount paid for insurance broker fees | 49433 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | 2278A |
Policy instance | 5 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 5 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $927 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $8,870 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $927 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 2278A |
Policy instance | 4 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 5 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $8,965 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $88,960 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,965 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 76380 |
Policy instance | 3 |
Insurance contract or identification number | 76380 | Number of Individuals Covered | 876 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $4,121 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $145,908 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $4,121 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 1 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 2066 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $5,230 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $321,686 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,230 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 1 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 1955 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $5,446 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $327,025 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,446 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 2 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 47 | 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 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $227,372 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 76380 |
Policy instance | 3 |
Insurance contract or identification number | 76380 | Number of Individuals Covered | 825 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $3,419 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $127,831 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $3,419 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | 2278A |
Policy instance | 5 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 7 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $563 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $6,626 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $563 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | GL163098 |
Policy instance | 6 |
Insurance contract or identification number | GL163098 | Number of Individuals Covered | 2024 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $46,106 | Total amount of fees paid to insurance company | USD $23,692 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $799,986 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $46,106 | Amount paid for insurance broker fees | 23692 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 2278A |
Policy instance | 4 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 7 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $8,720 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $95,443 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $8,720 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 543224 |
Policy instance | 1 |
Insurance contract or identification number | 543224 | Number of Individuals Covered | 1882 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $35,580 | Total amount of fees paid to insurance company | USD $10,746 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $737,066 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $35,580 | Amount paid for insurance broker fees | 10746 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 2 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 1639 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $5,182 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $301,956 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,182 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 76380 |
Policy instance | 4 |
Insurance contract or identification number | 76380 | Number of Individuals Covered | 652 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $2,925 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $113,211 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $2,925 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 2278A |
Policy instance | 5 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 8 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $10,386 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $103,864 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $10,386 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 3 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 35 | 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 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $255,691 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | 2278A |
Policy instance | 6 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 8 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $702 | Total amount of fees paid to insurance company | USD $0 | Life 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? | Yes | Commission paid to Insurance Broker | USD $702 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 2278A |
Policy instance | 5 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 1901 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $13,387 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $133,869 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $13,387 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 3 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 48 | 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 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $221,979 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | 2278A |
Policy instance | 6 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 1901 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $713 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $7,135 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $713 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 2 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 1650 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $5,072 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $291,474 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,072 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 543224 |
Policy instance | 1 |
Insurance contract or identification number | 543224 | Number of Individuals Covered | 1901 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $79,622 | Total amount of fees paid to insurance company | USD $31,755 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $1,082,277 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $79,622 | Amount paid for insurance broker fees | 31755 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 76380 |
Policy instance | 4 |
Insurance contract or identification number | 76380 | Number of Individuals Covered | 694 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $3,122 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $120,402 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $3,122 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | 02278A |
Policy instance | 5 |
Insurance contract or identification number | 02278A | Number of Individuals Covered | 7 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $533 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $5,328 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $533 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 76380 |
Policy instance | 4 |
Insurance contract or identification number | 76380 | Number of Individuals Covered | 759 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $3,507 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $135,203 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $3,507 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 3 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 25 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $140,241 | 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 | 12020763 |
Policy instance | 2 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 1626 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $5,067 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $287,928 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,067 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 543224 |
Policy instance | 1 |
Insurance contract or identification number | 543224 | Number of Individuals Covered | 1819 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $65,221 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $910,801 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $65,221 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 76380 |
Policy instance | 4 |
Insurance contract or identification number | 76380 | Number of Individuals Covered | 602 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $3,372 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $130,867 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $3,372 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | VAR206420 |
Policy instance | 6 |
Insurance contract or identification number | VAR206420 | Number of Individuals Covered | 1606 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $11,231 | Total amount of fees paid to insurance company | USD $7,412 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $384,919 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,301 | Amount paid for insurance broker fees | 7412 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES, FEES | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | 2278A |
Policy instance | 1 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 11 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $675 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $6,751 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $675 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 3 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 23 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $120,188 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 2 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 1558 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $5,046 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,724 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 2278A |
Policy instance | 5 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 11 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2018-04-03 | Total amount of commissions paid to insurance broker | USD $16,008 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $160,083 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $16,008 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 1 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 15 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $988 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 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 $56,857 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $988 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 2278A |
Policy instance | 2 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 9 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $15,694 | 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 | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $173,550 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $15,694 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 76380 |
Policy instance | 3 |
Insurance contract or identification number | 76380 | Number of Individuals Covered | 633 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $2,873 | 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 $111,073 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $2,873 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 4 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 1294 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $3,563 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,563 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | GL153187 |
Policy instance | 6 |
Insurance contract or identification number | GL153187 | Number of Individuals Covered | 1477 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $8,932 | 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 | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $283,787 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,932 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | 2278A |
Policy instance | 5 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 9 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $540 | 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 | 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 $5,897 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $540 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICE, INC. |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | 2278A |
Policy instance | 3 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 7 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $632 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $7,705 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $508 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 76380 |
Policy instance | 4 |
Insurance contract or identification number | 76380 | Number of Individuals Covered | 505 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $1,317 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $31,898 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $339 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 2278A |
Policy instance | 2 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 7 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $15,054 | 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 | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $176,977 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $11,841 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 1 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 12 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $339 | 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 $59,803 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $339 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 211373 |
Policy instance | 6 |
Insurance contract or identification number | 211373 | Number of Individuals Covered | 1368 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $6,820 | 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 | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $297,751 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,995 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 5 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 1144 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $3,294 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,942 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 211373 |
Policy instance | 7 |
Insurance contract or identification number | 211373 | Number of Individuals Covered | 1209 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $986 | 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 | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $48,065 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $986 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 6 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 1033 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $2,911 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,911 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 76380 |
Policy instance | 5 |
Insurance contract or identification number | 76380 | Number of Individuals Covered | 483 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $2,017 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $86,833 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,017 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | 2278A |
Policy instance | 3 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 8 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $584 | 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 | 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 $5,107 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $584 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 2278A |
Policy instance | 2 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 8 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $11,531 | 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 | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $101,714 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $11,531 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 1 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 15 | 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 | 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 $51,682 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
Policy contract number | 2278A |
Policy instance | 4 |
Insurance contract or identification number | 2278A | Number of Individuals Covered | 8 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $2,608 | 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 | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $40,400 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $2,608 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 6 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 947 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $2,825 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,825 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
Policy contract number | 02278A |
Policy instance | 5 |
Insurance contract or identification number | 02278A | Number of Individuals Covered | 8 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $14,625 | 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 | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $146,249 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,625 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 06380 |
Policy instance | 4 |
Insurance contract or identification number | 06380 | Number of Individuals Covered | 304 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $1,868 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $79,369 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,868 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 211373 |
Policy instance | 3 |
Insurance contract or identification number | 211373 | Number of Individuals Covered | 1135 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $1,701 | 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 | 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 $72,218 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,701 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 2 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 15 | 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 | 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 $49,941 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 211373 |
Policy instance | 1 |
Insurance contract or identification number | 211373 | Number of Individuals Covered | 1135 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $3,967 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $154,503 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,967 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 211373 |
Policy instance | 1 |
Insurance contract or identification number | 211373 | Number of Individuals Covered | 1232 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $4,726 | 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 $189,035 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
Policy contract number | 02278A |
Policy instance | 5 |
Insurance contract or identification number | 02278A | Number of Individuals Covered | 11 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $17,205 | 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 | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $170,810 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 6 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 972 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $2,736 | 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 $110,309 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 06380 |
Policy instance | 4 |
Insurance contract or identification number | 06380 | Number of Individuals Covered | 283 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $2,175 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $84,049 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 211373 |
Policy instance | 3 |
Insurance contract or identification number | 211373 | Number of Individuals Covered | 1142 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $2,117 | 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 | 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 $84,665 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 2 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 12 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | 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? | 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 $37,362 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 06380 |
Policy instance | 1 |
Insurance contract or identification number | 06380 | Number of Individuals Covered | 261 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $1,998 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $70,574 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,998 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12020763 |
Policy instance | 6 |
Insurance contract or identification number | 12020763 | Number of Individuals Covered | 944 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $2,609 | 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 $101,476 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,609 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 211373 |
Policy instance | 5 |
Insurance contract or identification number | 211373 | Number of Individuals Covered | 1142 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $1,948 | 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 | 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 $77,930 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,948 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 34394 |
Policy instance | 4 |
Insurance contract or identification number | 34394 | Number of Individuals Covered | 7 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | 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? | 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 $32,000 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 211373 |
Policy instance | 2 |
Insurance contract or identification number | 211373 | Number of Individuals Covered | 1142 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $4,515 | 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 $180,610 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,515 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
Policy contract number | 02278A |
Policy instance | 3 |
Insurance contract or identification number | 02278A | Number of Individuals Covered | 9 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $13,887 | 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 | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $137,725 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,887 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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