401k Plan data: PC CARE CORP HEALTH PLAN plan

PC CARE CORP HEALTH PLAN 401k Plan overview

Plan Name	PC CARE CORP HEALTH PLAN
Plan identification number	501

PC CARE CORP HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Other welfare benefit cover

401k Sponsoring company profile

PC CARE CORP DBA PEARL CITY NURSING HOME has sponsored the creation of one or more 401k plans.

Company Name: PC CARE CORP DBA PEARL CITY NURSING HOME

Employer identification number (EIN): 990294020

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PC CARE CORP HEALTH PLAN

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

Plan Statistics for PC CARE CORP HEALTH PLAN

401k plan membership statisitcs for PC CARE CORP HEALTH PLAN

Measure Date Value
2022: PC CARE CORP HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 253
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 204
Total of all active and inactive participants 2022-01-01 204
2021: PC CARE CORP HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 265
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 253
Total of all active and inactive participants 2021-01-01 253
2020: PC CARE CORP HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 257
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 265
Total of all active and inactive participants 2020-01-01 265
2019: PC CARE CORP HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 240
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 257
Total of all active and inactive participants 2019-01-01 257
2018: PC CARE CORP HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 140
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 240
Total of all active and inactive participants 2018-01-01 240
2017: PC CARE CORP HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 161
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 140
Total of all active and inactive participants 2017-01-01 140
2016: PC CARE CORP HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 150
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 161
Total of all active and inactive participants 2016-01-01 161
2015: PC CARE CORP HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 150
Total of all active and inactive participants 2015-01-01 150
2014: PC CARE CORP HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 159
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 145
Total of all active and inactive participants 2014-01-01 145
2013: PC CARE CORP HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 159
Number of retired or separated participants receiving benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 159
2012: PC CARE CORP HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 148
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 155
Number of retired or separated participants receiving benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 155
2011: PC CARE CORP HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 152
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 148
Number of retired or separated participants receiving benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 148
2010: PC CARE CORP HEALTH PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 142
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 152
Number of retired or separated participants receiving benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 152
2009: PC CARE CORP HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 135
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 141
Number of retired or separated participants receiving benefits 2009-01-01 1
Total of all active and inactive participants 2009-01-01 142

Measure	Date	Value
2022: PC CARE CORP HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	253
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	204
Total of all active and inactive participants	2022-01-01	204
2021: PC CARE CORP HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	265
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	253
Total of all active and inactive participants	2021-01-01	253
2020: PC CARE CORP HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	257
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	265
Total of all active and inactive participants	2020-01-01	265
2019: PC CARE CORP HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	240
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	257
Total of all active and inactive participants	2019-01-01	257
2018: PC CARE CORP HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	140
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	240
Total of all active and inactive participants	2018-01-01	240
2017: PC CARE CORP HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	161
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	140
Total of all active and inactive participants	2017-01-01	140
2016: PC CARE CORP HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	150
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	161
Total of all active and inactive participants	2016-01-01	161
2015: PC CARE CORP HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	150
Total of all active and inactive participants	2015-01-01	150
2014: PC CARE CORP HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	159
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	145
Total of all active and inactive participants	2014-01-01	145
2013: PC CARE CORP HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	159
Number of retired or separated participants receiving benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	159
2012: PC CARE CORP HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	148
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	155
Number of retired or separated participants receiving benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	155
2011: PC CARE CORP HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	152
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	148
Number of retired or separated participants receiving benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	148
2010: PC CARE CORP HEALTH PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	142
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	152
Number of retired or separated participants receiving benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	152
2009: PC CARE CORP HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	141
Number of retired or separated participants receiving benefits	2009-01-01	1
Total of all active and inactive participants	2009-01-01	142

Form 5500 Responses for PC CARE CORP HEALTH PLAN

2022: PC CARE CORP HEALTH 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 benefit arrangement – Insurance	Yes
2021: PC CARE CORP HEALTH 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 benefit arrangement – Insurance	Yes
2020: PC CARE CORP HEALTH PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: PC CARE CORP HEALTH PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: PC CARE CORP HEALTH PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: PC CARE CORP HEALTH PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: PC CARE CORP HEALTH PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: PC CARE CORP HEALTH PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: PC CARE CORP HEALTH PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: PC CARE CORP HEALTH PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: PC CARE CORP HEALTH PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: PC CARE CORP HEALTH PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: PC CARE CORP HEALTH PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: PC CARE CORP HEALTH PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

159410

Policy instance

Insurance contract or identification number	159410
Number of Individuals Covered	204
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $1,846
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $12,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,846
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

208611

Policy instance

Insurance contract or identification number	208611
Number of Individuals Covered	16
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $54
Total amount of fees paid to insurance company	USD $11
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $360
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
Amount paid for insurance broker fees	11
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

159410

Policy instance

Insurance contract or identification number	159410
Number of Individuals Covered	237
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $2,045
Total amount of fees paid to insurance company	USD $434
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $13,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,045
Amount paid for insurance broker fees	434
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

30871

Policy instance

Insurance contract or identification number	30871
Number of Individuals Covered	27
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
Welfare Benefit Premiums Paid to Carrier	USD $222,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

159410

Policy instance

Insurance contract or identification number	159410
Number of Individuals Covered	238
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,678
Total amount of fees paid to insurance company	USD $335
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $11,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,678
Amount paid for insurance broker fees	335
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

159410

Policy instance

Insurance contract or identification number	159410
Number of Individuals Covered	257
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,643
Total amount of fees paid to insurance company	USD $277
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $10,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,643
Amount paid for insurance broker fees	277
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

159410

Policy instance

Insurance contract or identification number	159410
Number of Individuals Covered	240
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $988
Total amount of fees paid to insurance company	USD $53
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $6,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $988
Amount paid for insurance broker fees	53
Insurance broker organization code?	3

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-2

Policy instance

Insurance contract or identification number	74613-2
Number of Individuals Covered	0
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
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LTD. (National Association of Insurance Commissioners NAIC id number: 64343 )

Policy contract number

40557-100

Policy instance

Insurance contract or identification number	40557-100
Number of Individuals Covered	113
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $508
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $4,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $508
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-1

Policy instance

Insurance contract or identification number	74613-1
Number of Individuals Covered	154
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
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 $1,017,929
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

30871

Policy instance

Insurance contract or identification number	30871
Number of Individuals Covered	27
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $197,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-1

Policy instance

Insurance contract or identification number	74613-1
Number of Individuals Covered	177
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
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
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $894,468
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-2

Policy instance

Insurance contract or identification number	74613-2
Number of Individuals Covered	1
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
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
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LTD. (National Association of Insurance Commissioners NAIC id number: 64343 )

Policy contract number

40557-100

Policy instance

Insurance contract or identification number	40557-100
Number of Individuals Covered	276
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,132
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,132
Insurance broker organization code?	3
Insurance broker name	ATLAS INSURANCE AGENCY

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

30871

Policy instance

Insurance contract or identification number	30871
Number of Individuals Covered	29
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $193,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LTD. (National Association of Insurance Commissioners NAIC id number: 64343 )

Policy contract number

40557-100

Policy instance

Insurance contract or identification number	40557-100
Number of Individuals Covered	272
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,162
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,162
Insurance broker organization code?	3
Insurance broker name	ATLAS INSURANCE AGENCY

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

30871

Policy instance

Insurance contract or identification number	30871
Number of Individuals Covered	33
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $172,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-1

Policy instance

Insurance contract or identification number	74613-1
Number of Individuals Covered	185
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,015,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-2

Policy instance

Insurance contract or identification number	74613-2
Number of Individuals Covered	0
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-1

Policy instance

Insurance contract or identification number	74613-1
Number of Individuals Covered	183
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $990,829
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

30871

Policy instance

Insurance contract or identification number	30871
Number of Individuals Covered	31
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $157,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LTD. (National Association of Insurance Commissioners NAIC id number: 64343 )

Policy contract number

40557-100

Policy instance

Insurance contract or identification number	40557-100
Number of Individuals Covered	273
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $1,021
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISABILITY AD
Welfare Benefit Premiums Paid to Carrier	USD $9,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,021
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ATLAS INSURANCE AGENCY

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-2

Policy instance

Insurance contract or identification number	74613-2
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-2

Policy instance

Insurance contract or identification number	74613-2
Number of Individuals Covered	0
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LTD. (National Association of Insurance Commissioners NAIC id number: 64343 )

Policy contract number

40557-100

Policy instance

Insurance contract or identification number	40557-100
Number of Individuals Covered	133
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $612
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISABILITY AD
Welfare Benefit Premiums Paid to Carrier	USD $4,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $612
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ATLAS INSURANCE AGENCY

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

30871

Policy instance

Insurance contract or identification number	30871
Number of Individuals Covered	26
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $156,337
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-1

Policy instance

Insurance contract or identification number	74613-1
Number of Individuals Covered	184
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $907,425
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

30871

Policy instance

Insurance contract or identification number	30871
Number of Individuals Covered	32
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $165,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LTD. (National Association of Insurance Commissioners NAIC id number: 64343 )

Policy contract number

40557-100

Policy instance

Insurance contract or identification number	40557-100
Number of Individuals Covered	132
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $551
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $4,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-2

Policy instance

Insurance contract or identification number	74613-2
Number of Individuals Covered	0
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-1

Policy instance

Insurance contract or identification number	74613-1
Number of Individuals Covered	177
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $851,740
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

30871

Policy instance

Insurance contract or identification number	30871
Number of Individuals Covered	34
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $126,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-1

Policy instance

Insurance contract or identification number	74613-1
Number of Individuals Covered	166
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $772,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LTD. (National Association of Insurance Commissioners NAIC id number: 64343 )

Policy contract number

40557-100

Policy instance

Insurance contract or identification number	40557-100
Number of Individuals Covered	278
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,140
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

74613-2

Policy instance

Insurance contract or identification number	74613-2
Number of Individuals Covered	0
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	PC CARE CORP DBA PEARL CITY NURSING HOME
Employer identification number (EIN):	990294020
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities