ADELFI CREDIT UNION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ADELFI CREDIT UNION HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 95 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 97 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 2 |
| Total of all active and inactive participants | 2022-01-01 | 99 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 99 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 96 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| 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 | 96 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 98 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 97 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 2 |
| Total of all active and inactive participants | 2020-01-01 | 100 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 110 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 86 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 4 |
| Total of all active and inactive participants | 2019-01-01 | 95 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 124 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 106 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 1 |
| Total of all active and inactive participants | 2018-01-01 | 110 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 142 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 139 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 139 |
| 2016: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 148 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 146 |
| Number of retired or separated participants receiving benefits | 2016-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-12-01 | 0 |
| Total of all active and inactive participants | 2016-12-01 | 146 |
| 2015: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 142 |
| Number of retired or separated participants receiving benefits | 2015-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-12-01 | 0 |
| Total of all active and inactive participants | 2015-12-01 | 142 |
| 2014: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-12-01 | 168 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-12-01 | 152 |
| Number of retired or separated participants receiving benefits | 2014-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-12-01 | 0 |
| Total of all active and inactive participants | 2014-12-01 | 152 |
| 2013: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-12-01 | 213 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-12-01 | 165 |
| Number of retired or separated participants receiving benefits | 2013-12-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2013-12-01 | 0 |
| Total of all active and inactive participants | 2013-12-01 | 168 |
| 2012: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-12-01 | 234 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-12-01 | 201 |
| Number of retired or separated participants receiving benefits | 2012-12-01 | 12 |
| Number of other retired or separated participants entitled to future benefits | 2012-12-01 | 0 |
| Total of all active and inactive participants | 2012-12-01 | 213 |
| 2011: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-12-01 | 235 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-12-01 | 229 |
| Number of retired or separated participants receiving benefits | 2011-12-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2011-12-01 | 0 |
| Total of all active and inactive participants | 2011-12-01 | 234 |
| 2010: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-12-01 | 242 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-12-01 | 227 |
| Number of retired or separated participants receiving benefits | 2010-12-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2010-12-01 | 0 |
| Total of all active and inactive participants | 2010-12-01 | 230 |
| 2009: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-12-01 | 322 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-12-01 | 260 |
| Number of retired or separated participants receiving benefits | 2009-12-01 | 21 |
| Number of other retired or separated participants entitled to future benefits | 2009-12-01 | 0 |
| Total of all active and inactive participants | 2009-12-01 | 281 |
| 2022: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan 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: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Submission has been amended | No |
| 2016-12-01 | This submission is the final filing | No |
| 2016-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2016-12-01 | Plan is a collectively bargained plan | No |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-12-01 | Type of plan entity | Single employer plan |
| 2014-12-01 | Submission has been amended | No |
| 2014-12-01 | This submission is the final filing | No |
| 2014-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-12-01 | Plan is a collectively bargained plan | No |
| 2014-12-01 | Plan funding arrangement – Insurance | Yes |
| 2014-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-12-01 | Type of plan entity | Single employer plan |
| 2013-12-01 | Submission has been amended | No |
| 2013-12-01 | This submission is the final filing | No |
| 2013-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-12-01 | Plan is a collectively bargained plan | No |
| 2013-12-01 | Plan funding arrangement – Insurance | Yes |
| 2013-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-12-01 | Type of plan entity | Single employer plan |
| 2012-12-01 | Submission has been amended | No |
| 2012-12-01 | This submission is the final filing | No |
| 2012-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-12-01 | Plan is a collectively bargained plan | No |
| 2012-12-01 | Plan funding arrangement – Insurance | Yes |
| 2012-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-12-01 | Type of plan entity | Single employer plan |
| 2011-12-01 | Submission has been amended | No |
| 2011-12-01 | This submission is the final filing | No |
| 2011-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-12-01 | Plan is a collectively bargained plan | No |
| 2011-12-01 | Plan funding arrangement – Insurance | Yes |
| 2011-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2010 form 5500 responses |
|---|
| 2010-12-01 | Type of plan entity | Single employer plan |
| 2010-12-01 | Submission has been amended | No |
| 2010-12-01 | This submission is the final filing | No |
| 2010-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-12-01 | Plan is a collectively bargained plan | No |
| 2010-12-01 | Plan funding arrangement – Insurance | Yes |
| 2010-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: ADELFI CREDIT UNION HEALTH AND WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-12-01 | Type of plan entity | Single employer plan |
| 2009-12-01 | Submission has been amended | No |
| 2009-12-01 | This submission is the final filing | No |
| 2009-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-12-01 | Plan is a collectively bargained plan | No |
| 2009-12-01 | Plan funding arrangement – Insurance | Yes |
| 2009-12-01 | Plan benefit arrangement – Insurance | Yes |
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 15152 |
| Policy instance | 4 |
| Insurance contract or identification number | 15152 | | Number of Individuals Covered | 0 | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 178174 |
| Policy instance | 1 |
| Insurance contract or identification number | 178174 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,572 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $245,462 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,572 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12227672 |
| Policy instance | 2 |
| Insurance contract or identification number | 12227672 | | Number of Individuals Covered | 90 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,230 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12336 |
| Policy instance | 3 |
| Insurance contract or identification number | 12336 | | Number of Individuals Covered | 211 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,798 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 5 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 107 | | 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 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $4,333 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 ) |
| Policy contract number | 00 |
| Policy instance | 6 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,257 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $16,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $943 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 118500 |
| Policy instance | 7 |
| Insurance contract or identification number | 118500 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $10,172 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $478,489 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,172 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 00 |
| Policy instance | 8 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $100 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $2,488 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $75 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | 00 |
| Policy instance | 9 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $567 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $6,294 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $425 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 178174HNO |
| Policy instance | 10 |
| Insurance contract or identification number | 178174HNO | | Number of Individuals Covered | 99 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $15,304 | | Total amount of fees paid to insurance company | USD $2,500 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $668,715 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,304 | | Amount paid for insurance broker fees | 2500 | | Additional information about fees paid to insurance broker | 2022 Q1 GROW WITH US NEW BUSINESS INCENTIVE RISK | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 205601 |
| Policy instance | 11 |
| Insurance contract or identification number | 205601 | | Number of Individuals Covered | 97 | | 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 $991 | | 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 $79,263 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 991 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 707995 |
| Policy instance | 12 |
| Insurance contract or identification number | 707995 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,225 | | Total amount of fees paid to insurance company | USD $212 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $9,264 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,225 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12336 |
| Policy instance | 3 |
| Insurance contract or identification number | 12336 | | Number of Individuals Covered | 198 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $94,062 | | 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 | 12227672 |
| Policy instance | 2 |
| Insurance contract or identification number | 12227672 | | Number of Individuals Covered | 87 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 915783 |
| Policy instance | 1 |
| Insurance contract or identification number | 915783 | | Number of Individuals Covered | 59 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $27,726 | | Total amount of fees paid to insurance company | USD $2,979 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,107,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,726 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 00 |
| Policy instance | 8 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $429 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $5,805 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $322 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 15152 |
| Policy instance | 4 |
| Insurance contract or identification number | 15152 | | Number of Individuals Covered | 96 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 5 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 107 | | 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 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $4,649 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 ) |
| Policy contract number | 00 |
| Policy instance | 6 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,463 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $18,002 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,097 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 118500 |
| Policy instance | 7 |
| Insurance contract or identification number | 118500 | | Number of Individuals Covered | 66 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $8,225 | | Total amount of fees paid to insurance company | USD $340 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $460,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,225 | | Amount paid for insurance broker fees | 340 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | 00 |
| Policy instance | 9 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,201 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $10,921 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $901 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 205601 |
| Policy instance | 10 |
| Insurance contract or identification number | 205601 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $142 | | Total amount of fees paid to insurance company | USD $992 | | 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,ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $85,632 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 992 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12336 |
| Policy instance | 3 |
| Insurance contract or identification number | 12336 | | Number of Individuals Covered | 195 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $82,300 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 15152 |
| Policy instance | 4 |
| Insurance contract or identification number | 15152 | | Number of Individuals Covered | 1 | | 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 $188 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 5 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 104 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $5,269 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 ) |
| Policy contract number | 00 |
| Policy instance | 6 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,462 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $18,002 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,096 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 118500 |
| Policy instance | 7 |
| Insurance contract or identification number | 118500 | | Number of Individuals Covered | 66 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $9,008 | | Total amount of fees paid to insurance company | USD $1,360 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $450,515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,008 | | Amount paid for insurance broker fees | 1360 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 00 |
| Policy instance | 8 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $216 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $3,317 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $162 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 205601 |
| Policy instance | 10 |
| Insurance contract or identification number | 205601 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $148 | | Total amount of fees paid to insurance company | USD $1,081 | | 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,ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $93,064 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 1081 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12227672 |
| Policy instance | 2 |
| Insurance contract or identification number | 12227672 | | Number of Individuals Covered | 86 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,978 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 915783 |
| Policy instance | 1 |
| Insurance contract or identification number | 915783 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,037 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $975,619 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,037 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | 00 |
| Policy instance | 9 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,877 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $16,594 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,908 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 205601 |
| Policy instance | 10 |
| Insurance contract or identification number | 205601 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $182 | | Total amount of fees paid to insurance company | USD $1,037 | | 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,ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $91,061 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 1037 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 915783 |
| Policy instance | 1 |
| Insurance contract or identification number | 915783 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $25,865 | | Total amount of fees paid to insurance company | USD $2,556 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,034,589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,865 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12227672 |
| Policy instance | 2 |
| Insurance contract or identification number | 12227672 | | Number of Individuals Covered | 91 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,074 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12336 |
| Policy instance | 3 |
| Insurance contract or identification number | 12336 | | Number of Individuals Covered | 209 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,997 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 5 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 107 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $2,983 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 15152 |
| Policy instance | 4 |
| Insurance contract or identification number | 15152 | | Number of Individuals Covered | 1 | | 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 $29,528 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 ) |
| Policy contract number | 00 |
| Policy instance | 6 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,456 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,092 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 118500 |
| Policy instance | 7 |
| Insurance contract or identification number | 118500 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $8,379 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $421,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,379 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 00 |
| Policy instance | 8 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,089 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,481 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | 00 |
| Policy instance | 9 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $7,258 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,325 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0054346 |
| Policy instance | 1 |
| Insurance contract or identification number | W0054346 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $43,271 | | Total amount of fees paid to insurance company | USD $946 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,442,351 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,271 | | Amount paid for insurance broker fees | 946 | | Additional information about fees paid to insurance broker | BONUS OVERRIDE | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12227672 |
| Policy instance | 2 |
| Insurance contract or identification number | 12227672 | | Number of Individuals Covered | 110 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12336 |
| Policy instance | 3 |
| Insurance contract or identification number | 12336 | | Number of Individuals Covered | 298 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $135,528 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 15152 |
| Policy instance | 4 |
| Insurance contract or identification number | 15152 | | 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 $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,637 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | 00 |
| Policy instance | 6 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,506 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,146 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 5 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 125 | | 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 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $3,496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 118500 |
| Policy instance | 7 |
| Insurance contract or identification number | 118500 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $9,676 | | Total amount of fees paid to insurance company | USD $1,798 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $486,656 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,676 | | Amount paid for insurance broker fees | 1798 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | 00 |
| Policy instance | 8 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $232 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $174 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | 00 |
| Policy instance | 9 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,528 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,646 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 205601 |
| Policy instance | 10 |
| Insurance contract or identification number | 205601 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $311 | | Total amount of fees paid to insurance company | USD $1,236 | | 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,ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $111,234 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 1236 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12227672 |
| Policy instance | 2 |
| Insurance contract or identification number | 12227672 | | Number of Individuals Covered | 122 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,552 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12336 |
| Policy instance | 3 |
| Insurance contract or identification number | 12336 | | Number of Individuals Covered | 322 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $144,726 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 15152 |
| Policy instance | 4 |
| Insurance contract or identification number | 15152 | | Number of Individuals Covered | 7 | | 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 $38,306 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 5 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 147 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $3,591 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 ) |
| Policy contract number | 00 |
| Policy instance | 6 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,036 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,541 | | 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 | 118500 |
| Policy instance | 7 |
| Insurance contract or identification number | 118500 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $9,294 | | Total amount of fees paid to insurance company | USD $119 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $465,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,294 | | Amount paid for insurance broker fees | 119 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 00 |
| Policy instance | 8 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $232 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $174 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | 00 |
| Policy instance | 9 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $9,449 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LONG TERM CARE | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,087 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 205601 |
| Policy instance | 10 |
| Insurance contract or identification number | 205601 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $630 | | Total amount of fees paid to insurance company | USD $1,282 | | 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,ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $108,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 1282 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0054346 |
| Policy instance | 1 |
| Insurance contract or identification number | W0054346 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $37,581 | | Total amount of fees paid to insurance company | USD $1,065 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,406,416 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,581 | | Amount paid for insurance broker fees | 1065 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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