401k Plan data: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN plan

PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	PACIFIC COAST TITLE HEALTH AND WELFARE PLAN
Plan identification number	501

PACIFIC COAST TITLE HEALTH AND WELFARE PLAN Benefits

401k Plan Type

Welfare Benefit

Plan Features/Benefits

Health (other than dental or vision)
Life insurance
Dental
Vision
Long-term disability cover
Other welfare benefit cover
Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

PACIFIC COAST TITLE COMPANY has sponsored the creation of one or more 401k plans.

Company Name: PACIFIC COAST TITLE COMPANY

Employer identification number (EIN): 952569776

NAIC Classification: 531390
NAIC Description: Other Activities Related to Real Estate

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PACIFIC COAST TITLE HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2018-01-01
501 2017-01-01 BOBBIE NELSON
501 2016-01-01 STUART BOESCHE
501 2015-01-01 STUART BOESCHE
501 2014-01-01 STUART BOESCHE
501 2013-01-01 STUART BOESCHE
501 2011-01-01 STUART BOESCHE

Plan Statistics for PACIFIC COAST TITLE HEALTH AND WELFARE PLAN

401k plan membership statisitcs for PACIFIC COAST TITLE HEALTH AND WELFARE PLAN

Measure Date Value
2018: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 85
Number of retired or separated participants receiving benefits 2018-01-01 2
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 87
2017: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 120
Number of retired or separated participants receiving benefits 2017-01-01 1
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 121
2016: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 118
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 118
2015: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 112
Number of retired or separated participants receiving benefits 2015-01-01 3
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 115
2014: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 117
Number of retired or separated participants receiving benefits 2014-01-01 1
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 118
2013: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 127
Number of retired or separated participants receiving benefits 2013-01-01 2
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 129
2011: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 130
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 91
Number of retired or separated participants receiving benefits 2011-01-01 7
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 98
Total participants 2011-01-01 98

Measure	Date	Value
2018: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	85
Number of retired or separated participants receiving benefits	2018-01-01	2
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	87
2017: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	120
Number of retired or separated participants receiving benefits	2017-01-01	1
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	121
2016: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	118
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	118
2015: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	112
Number of retired or separated participants receiving benefits	2015-01-01	3
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	115
2014: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	117
Number of retired or separated participants receiving benefits	2014-01-01	1
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	118
2013: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	127
Number of retired or separated participants receiving benefits	2013-01-01	2
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	129
2011: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	130
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	91
Number of retired or separated participants receiving benefits	2011-01-01	7
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	98
Total participants	2011-01-01	98

Form 5500 Responses for PACIFIC COAST TITLE HEALTH AND WELFARE PLAN

2018: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: PACIFIC COAST TITLE HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

230899

Policy instance

Insurance contract or identification number	230899
Number of Individuals Covered	81
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $22,461
Total amount of fees paid to insurance company	USD $3
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $450,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,461
Amount paid for insurance broker fees	3
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	22
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $17,201
Total amount of fees paid to insurance company	USD $8,600
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $471,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,201
Insurance broker organization code?	3
Amount paid for insurance broker fees	8600
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

156835

Policy instance

Insurance contract or identification number	156835
Number of Individuals Covered	25
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,558
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,558
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

156835

Policy instance

Insurance contract or identification number	156835
Number of Individuals Covered	94
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,392
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,392
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98042121001

Policy instance

Insurance contract or identification number	98042121001
Number of Individuals Covered	151
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $933
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $933
Insurance broker organization code?	3

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	10
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,358
Total amount of fees paid to insurance company	USD $2,679
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $146,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,358
Insurance broker organization code?	3
Amount paid for insurance broker fees	2679
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0730657

Policy instance

Insurance contract or identification number	0730657
Number of Individuals Covered	153
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,176
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $82,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,176
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

230899

Policy instance

Insurance contract or identification number	230899
Number of Individuals Covered	60
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $18,993
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $353,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,993
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0730657

Policy instance

Insurance contract or identification number	0730657
Number of Individuals Covered	75
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,927
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $96,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,927
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INS. SERVICES, INC.

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98042121001

Policy instance

Insurance contract or identification number	98042121001
Number of Individuals Covered	171
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,291
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,291
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

156835

Policy instance

Insurance contract or identification number	156835
Number of Individuals Covered	120
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $10,647
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,647
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

156835

Policy instance

Insurance contract or identification number	156835
Number of Individuals Covered	29
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,908
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,908
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS AND INS. SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

603483

Policy instance

Insurance contract or identification number	603483
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
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
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
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	21
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $19,161
Total amount of fees paid to insurance company	USD $9,580
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $435,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,161
Insurance broker organization code?	3
Amount paid for insurance broker fees	9580
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	16
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $9,831
Total amount of fees paid to insurance company	USD $4,916
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $223,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,831
Insurance broker organization code?	3
Amount paid for insurance broker fees	4916
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	LISI, INC.

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	36
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,208
Total amount of fees paid to insurance company	USD $3,604
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $183,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,208
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	LISI, INC.

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	89
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $24,132
Total amount of fees paid to insurance company	USD $12,066
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $616,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,132
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	LISI, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

603483

Policy instance

Insurance contract or identification number	603483
Number of Individuals Covered	27
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,690
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $146,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,690
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

156835

Policy instance

Insurance contract or identification number	156835
Number of Individuals Covered	38
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,979
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,979
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N//A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS AND INS. SERVICES

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

156835

Policy instance

Insurance contract or identification number	156835
Number of Individuals Covered	112
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,475
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,475
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9804212

Policy instance

Insurance contract or identification number	9804212
Number of Individuals Covered	209
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,440
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,440
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

230899

Policy instance

Insurance contract or identification number	230899
Number of Individuals Covered	47
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $14,657
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $283,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,657
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0730657

Policy instance

Insurance contract or identification number	0730657
Number of Individuals Covered	254
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,102
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $121,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,102
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INS. SERVICES, INC.

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0730657

Policy instance

Insurance contract or identification number	0730657
Number of Individuals Covered	255
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,236
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $130,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,236
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INS. SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

230899

Policy instance

Insurance contract or identification number	230899
Number of Individuals Covered	46
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,587
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $191,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,587
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9804212

Policy instance

Insurance contract or identification number	9804212
Number of Individuals Covered	237
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,272
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,272
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

156835

Policy instance

Insurance contract or identification number	156835
Number of Individuals Covered	36
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,117
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,117
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N//A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS AND INS. SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

603483

Policy instance

Insurance contract or identification number	603483
Number of Individuals Covered	25
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,868
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $131,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,868
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

156835

Policy instance

Insurance contract or identification number	156835
Number of Individuals Covered	117
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $11,059
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,059
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	30
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $8,073
Total amount of fees paid to insurance company	USD $4,036
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $196,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,073
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	LISI, INC.

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	99
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $25,564
Total amount of fees paid to insurance company	USD $12,782
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $623,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,564
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	LISI, INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907493

Policy instance

Insurance contract or identification number	907493
Number of Individuals Covered	45
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,989
Total amount of fees paid to insurance company	USD $864
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LIFESTYLE AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $46,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,989
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERV

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0730657

Policy instance

Insurance contract or identification number	0730657
Number of Individuals Covered	240
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,287
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $98,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,287
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INS. SERVICES, INC.

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9804212

Policy instance

Insurance contract or identification number	9804212
Number of Individuals Covered	224
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,404
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,404
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907494

Policy instance

Insurance contract or identification number	907494
Number of Individuals Covered	127
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,612
Total amount of fees paid to insurance company	USD $304
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,612
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

230899

Policy instance

Insurance contract or identification number	230899
Number of Individuals Covered	31
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,249
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $193,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,249
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907492

Policy instance

Insurance contract or identification number	907492
Number of Individuals Covered	35
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,277
Total amount of fees paid to insurance company	USD $278
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,277
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERV.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

603483

Policy instance

Insurance contract or identification number	603483
Number of Individuals Covered	25
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,598
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $155,157
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,598
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	106
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $22,375
Total amount of fees paid to insurance company	USD $10,008
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $579,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,375
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	LISI, INC.

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	41
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,066
Total amount of fees paid to insurance company	USD $3,160
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $183,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,066
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	LISI, INC.

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

276155

Policy instance

Insurance contract or identification number	276155
Number of Individuals Covered	204
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $38,956
Total amount of fees paid to insurance company	USD $15,582
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $744,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907492

Policy instance

Insurance contract or identification number	907492
Number of Individuals Covered	27
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,844
Total amount of fees paid to insurance company	USD $254
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,489
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: 00000 )

Policy contract number

603483

Policy instance

Insurance contract or identification number	603483
Number of Individuals Covered	24
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,413
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $61,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0730657

Policy instance

Insurance contract or identification number	0730657
Number of Individuals Covered	208
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,973
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $91,763
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: 00000 )

Policy contract number

230899

Policy instance

Insurance contract or identification number	230899
Number of Individuals Covered	48
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,144
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $186,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9804212

Policy instance

Insurance contract or identification number	9804212
Number of Individuals Covered	165
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $279
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907494

Policy instance

Insurance contract or identification number	907494
Number of Individuals Covered	94
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $920
Total amount of fees paid to insurance company	USD $138
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907493

Policy instance

Insurance contract or identification number	907493
Number of Individuals Covered	35
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,738
Total amount of fees paid to insurance company	USD $634
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LIFESTYLE AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $42,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	PACIFIC COAST TITLE COMPANY
Employer identification number (EIN):	952569776
NAIC Classification:	531390
NAIC Description:	Other Activities Related to Real Estate

Plan id#	Filing Submission Date	Name of Administrator
501	2018-01-01
501	2017-01-01	BOBBIE NELSON
501	2016-01-01	STUART BOESCHE
501	2015-01-01	STUART BOESCHE
501	2014-01-01	STUART BOESCHE
501	2013-01-01	STUART BOESCHE
501	2011-01-01	STUART BOESCHE