AVAMERE HEALTH SERVICES, INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan AVAMERE HEALTH SERVICES, INC. HEALTH & WELFARE PLAN
401k plan membership statisitcs for AVAMERE HEALTH SERVICES, INC. HEALTH & WELFARE PLAN
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 16-014752-000 |
| Policy instance | 6 |
| Insurance contract or identification number | 16-014752-000 | | Number of Individuals Covered | 1206 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of fees paid to insurance company | USD $45,283 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $711,087 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 45283 | | Additional information about fees paid to insurance broker | ADMINISTRATION VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0105361 |
| Policy instance | 12 |
| Insurance contract or identification number | R0105361 | | Number of Individuals Covered | 3114 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $97,036 | | Total amount of fees paid to insurance company | USD $10,258 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $648,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,334 | | Amount paid for insurance broker fees | 243 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 7978 |
| Policy instance | 1 |
| Insurance contract or identification number | 7978 | | Number of Individuals Covered | 382 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,293,031 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12288060 |
| Policy instance | 2 |
| Insurance contract or identification number | 12288060 | | Number of Individuals Covered | 1671 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,555 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,555 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 3 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 1499 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $12,686 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $907,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,686 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 4 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 707 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,126 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $366,533 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,126 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35557 |
| Policy instance | 5 |
| Insurance contract or identification number | 35557 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $256,954 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 8454713 |
| Policy instance | 11 |
| Insurance contract or identification number | 8454713 | | Number of Individuals Covered | 1974 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $91,068 | | Total amount of fees paid to insurance company | USD $12,588 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $583,214 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,843 | | Amount paid for insurance broker fees | 5612 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 1978000 |
| Policy instance | 7 |
| Insurance contract or identification number | 1978000 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $237,225 | | 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 | 094303 |
| Policy instance | 8 |
| Insurance contract or identification number | 094303 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $254 | | Total amount of fees paid to insurance company | USD $51 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,538 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $254 | | Amount paid for insurance broker fees | 51 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094304 |
| Policy instance | 9 |
| Insurance contract or identification number | 094304 | | Number of Individuals Covered | 1071 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $56,111 | | Total amount of fees paid to insurance company | USD $7,481 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $346,714 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,111 | | Amount paid for insurance broker fees | 7481 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 604748 |
| Policy instance | 10 |
| Insurance contract or identification number | 604748 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,463 | | Total amount of fees paid to insurance company | USD $2,926 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $156,975 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,463 | | Amount paid for insurance broker fees | 2926 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 16-014752-000 |
| Policy instance | 6 |
| Insurance contract or identification number | 16-014752-000 | | Number of Individuals Covered | 2058 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $80,479 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $879,047 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 52285 | | Additional information about fees paid to insurance broker | ADMINISTRATION VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35557 |
| Policy instance | 5 |
| Insurance contract or identification number | 35557 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $285,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 4 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 975 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $6,133 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $520,405 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,133 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 3 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 2267 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $16,032 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,360,411 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,032 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 7978 |
| Policy instance | 1 |
| Insurance contract or identification number | 7978 | | Number of Individuals Covered | 429 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $3,306 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,029,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3306 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 1978000 |
| Policy instance | 7 |
| Insurance contract or identification number | 1978000 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $458,745 | | 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 | 094302 |
| Policy instance | 8 |
| Insurance contract or identification number | 094302 | | Number of Individuals Covered | 808 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,856 | | Total amount of fees paid to insurance company | USD $766 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $38,290 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,856 | | Amount paid for insurance broker fees | 766 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094303 |
| Policy instance | 9 |
| Insurance contract or identification number | 094303 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $338 | | Total amount of fees paid to insurance company | USD $68 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,378 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $338 | | Amount paid for insurance broker fees | 68 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12288060 |
| Policy instance | 2 |
| Insurance contract or identification number | 12288060 | | Number of Individuals Covered | 1852 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $7,272 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,272 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0105361 |
| Policy instance | 14 |
| Insurance contract or identification number | R0105361 | | Number of Individuals Covered | 4049 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $164,949 | | Total amount of fees paid to insurance company | USD $26,705 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $842,983 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,260 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 26697 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 8454713 |
| Policy instance | 13 |
| Insurance contract or identification number | 8454713 | | Number of Individuals Covered | 2335 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $188,718 | | Total amount of fees paid to insurance company | USD $35,082 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $721,673 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $75,093 | | Amount paid for insurance broker fees | 20352 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 801368 |
| Policy instance | 12 |
| Insurance contract or identification number | 801368 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $5,432 | | Total amount of fees paid to insurance company | USD $724 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,212 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,432 | | Amount paid for insurance broker fees | 724 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 604748 |
| Policy instance | 11 |
| Insurance contract or identification number | 604748 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $5,292 | | Total amount of fees paid to insurance company | USD $2,584 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $118,489 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,292 | | Amount paid for insurance broker fees | 2584 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094304 |
| Policy instance | 10 |
| Insurance contract or identification number | 094304 | | Number of Individuals Covered | 2577 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $53,805 | | Total amount of fees paid to insurance company | USD $7,174 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $412,119 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,805 | | Amount paid for insurance broker fees | 7174 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 7978 |
| Policy instance | 1 |
| Insurance contract or identification number | 7978 | | Number of Individuals Covered | 492 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,266,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12288060 |
| Policy instance | 2 |
| Insurance contract or identification number | 12288060 | | Number of Individuals Covered | 1884 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,766 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,766 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 3 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 1729 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $9,117 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $485,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,117 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 4 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 1105 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,182 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $276,022 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,182 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35557 |
| Policy instance | 5 |
| Insurance contract or identification number | 35557 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $121,320 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 16-014752-000 |
| Policy instance | 6 |
| Insurance contract or identification number | 16-014752-000 | | Number of Individuals Covered | 2058 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $29,881 | | Welfare Benefit Premiums Paid to Carrier | USD $398,578 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 24561 | | Additional information about fees paid to insurance broker | ADMINISTRATION VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 1978000 |
| Policy instance | 7 |
| Insurance contract or identification number | 1978000 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $216,784 | | 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 | 801368 |
| Policy instance | 12 |
| Insurance contract or identification number | 801368 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,626 | | Total amount of fees paid to insurance company | USD $219 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,251 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,626 | | Amount paid for insurance broker fees | 219 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 604748 |
| Policy instance | 11 |
| Insurance contract or identification number | 604748 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,152 | | Total amount of fees paid to insurance company | USD $701 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,370 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,152 | | Amount paid for insurance broker fees | 701 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094304 |
| Policy instance | 10 |
| Insurance contract or identification number | 094304 | | Number of Individuals Covered | 1329 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $26,446 | | Total amount of fees paid to insurance company | USD $2,204 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $121,651 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,446 | | Amount paid for insurance broker fees | 2204 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094303 |
| Policy instance | 9 |
| Insurance contract or identification number | 094303 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $176 | | Total amount of fees paid to insurance company | USD $22 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $176 | | Amount paid for insurance broker fees | 22 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094302 |
| Policy instance | 8 |
| Insurance contract or identification number | 094302 | | Number of Individuals Covered | 575 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,936 | | Total amount of fees paid to insurance company | USD $277 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $18,866 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,936 | | Amount paid for insurance broker fees | 277 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094302 |
| Policy instance | 3 |
| Insurance contract or identification number | 094302 | | Number of Individuals Covered | 584 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $3,001 | | Total amount of fees paid to insurance company | USD $340 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC. DEATH/DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $44,339 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,001 | | Amount paid for insurance broker fees | 340 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12288060 |
| Policy instance | 4 |
| Insurance contract or identification number | 12288060 | | Number of Individuals Covered | 2052 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $4,924 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,924 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 5 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 1682 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $12,411 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $941,666 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,411 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 6 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 1104 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $7,315 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $554,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,315 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094304 |
| Policy instance | 7 |
| Insurance contract or identification number | 094304 | | Number of Individuals Covered | 1420 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $51,532 | | Total amount of fees paid to insurance company | USD $3,269 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $370,620 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $51,532 | | Amount paid for insurance broker fees | 3269 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008454713 |
| Policy instance | 8 |
| Insurance contract or identification number | 0008454713 | | Number of Individuals Covered | 4614 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $211,379 | | Total amount of fees paid to insurance company | USD $50,501 | | Other welfare benefits provided | VWB (ACCIDENT, ISTDPROTEC) | | Welfare Benefit Premiums Paid to Carrier | USD $641,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $83,492 | | Amount paid for insurance broker fees | 29647 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 604748 |
| Policy instance | 9 |
| Insurance contract or identification number | 604748 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $8,729 | | Total amount of fees paid to insurance company | USD $1,169 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $108,415 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,729 | | Amount paid for insurance broker fees | 1169 | | Additional information about fees paid to insurance broker | ADDTL COMPENSATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35557 |
| Policy instance | 10 |
| Insurance contract or identification number | 35557 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of fees paid to insurance company | USD $245 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $255,863 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 245 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 801368 |
| Policy instance | 11 |
| Insurance contract or identification number | 801368 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $7,498 | | Total amount of fees paid to insurance company | USD $402 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,245 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,498 | | Amount paid for insurance broker fees | 402 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0105361 |
| Policy instance | 12 |
| Insurance contract or identification number | R0105361 | | Number of Individuals Covered | 6604 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $316,246 | | Total amount of fees paid to insurance company | USD $45,616 | | Other welfare benefits provided | VOLUNTARY HOSPITALIZATION | | Welfare Benefit Premiums Paid to Carrier | USD $733,989 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $178,784 | | Amount paid for insurance broker fees | 17069 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 16-014752-000 |
| Policy instance | 13 |
| Insurance contract or identification number | 16-014752-000 | | Number of Individuals Covered | 2058 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of fees paid to insurance company | USD $51,614 | | Welfare Benefit Premiums Paid to Carrier | USD $788,568 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 38327 | | Additional information about fees paid to insurance broker | ADMINISTRATION VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094303 |
| Policy instance | 2 |
| Insurance contract or identification number | 094303 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $399 | | Total amount of fees paid to insurance company | USD $36 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,987 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $399 | | Amount paid for insurance broker fees | 36 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 7978 |
| Policy instance | 1 |
| Insurance contract or identification number | 7978 | | Number of Individuals Covered | 482 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of fees paid to insurance company | USD $5,059 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,747,182 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 5059 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 1978000 |
| Policy instance | 14 |
| Insurance contract or identification number | 1978000 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $1,200 | | Total amount of fees paid to insurance company | USD $320 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $354,071 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,200 | | Amount paid for insurance broker fees | 320 | | Additional information about fees paid to insurance broker | NON-MONETARY COMP | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 7978 |
| Policy instance | 1 |
| Insurance contract or identification number | 7978 | | Number of Individuals Covered | 378 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of fees paid to insurance company | USD $25 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,151,078 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 25 | | Additional information about fees paid to insurance broker | NON-MONETARY COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094303 |
| Policy instance | 2 |
| Insurance contract or identification number | 094303 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $439 | | Total amount of fees paid to insurance company | USD $19 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $439 | | Amount paid for insurance broker fees | 19 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094302 |
| Policy instance | 3 |
| Insurance contract or identification number | 094302 | | Number of Individuals Covered | 401 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $3,144 | | Total amount of fees paid to insurance company | USD $172 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC. DEATH/DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $47,548 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,144 | | Amount paid for insurance broker fees | 172 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12288060 |
| Policy instance | 4 |
| Insurance contract or identification number | 12288060 | | Number of Individuals Covered | 1928 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $3,167 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,167 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 5 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 1567 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $12,573 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $826,114 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,573 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 6 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 981 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $6,392 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $419,984 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,392 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094304 |
| Policy instance | 7 |
| Insurance contract or identification number | 094304 | | Number of Individuals Covered | 1020 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $42,107 | | Total amount of fees paid to insurance company | USD $786 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $282,231 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,107 | | Amount paid for insurance broker fees | 786 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 0008454713 |
| Policy instance | 8 |
| Insurance contract or identification number | 0008454713 | | Number of Individuals Covered | 5159 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $300,503 | | Total amount of fees paid to insurance company | USD $42,921 | | Other welfare benefits provided | VWB (ACCIDENT, ISTDPROTEC) | | Welfare Benefit Premiums Paid to Carrier | USD $665,385 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $179,061 | | Amount paid for insurance broker fees | 19955 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 604748 |
| Policy instance | 9 |
| Insurance contract or identification number | 604748 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $1,038 | | Total amount of fees paid to insurance company | USD $50 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $79,828 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,038 | | Amount paid for insurance broker fees | 50 | | Additional information about fees paid to insurance broker | ADDTL COMPENSATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35557 |
| Policy instance | 10 |
| Insurance contract or identification number | 35557 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $249,965 | | 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 | 801368 |
| Policy instance | 11 |
| Insurance contract or identification number | 801368 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $3,173 | | Total amount of fees paid to insurance company | USD $136 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,183 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,173 | | Amount paid for insurance broker fees | 136 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 908369 |
| Policy instance | 12 |
| Insurance contract or identification number | 908369 | | Number of Individuals Covered | 1924 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $61,633 | | Welfare Benefit Premiums Paid to Carrier | USD $821,775 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,633 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 5 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 1587 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $13,905 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $853,733 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,905 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12288060 |
| Policy instance | 4 |
| Insurance contract or identification number | 12288060 | | Number of Individuals Covered | 1683 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $4,911 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,911 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094302 |
| Policy instance | 3 |
| Insurance contract or identification number | 094302 | | Number of Individuals Covered | 422 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $3,773 | | Total amount of fees paid to insurance company | USD $904 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC. DEATH/DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $66,097 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,773 | | Amount paid for insurance broker fees | 904 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094303 |
| Policy instance | 2 |
| Insurance contract or identification number | 094303 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $458 | | Total amount of fees paid to insurance company | USD $57 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,202 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $458 | | Amount paid for insurance broker fees | 57 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 7978 |
| Policy instance | 1 |
| Insurance contract or identification number | 7978 | | Number of Individuals Covered | 341 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of fees paid to insurance company | USD $1,787 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,029,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1787 | | Additional information about fees paid to insurance broker | RETENTION BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEITS PLANNING LLC |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 6 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 700 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $4,987 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $306,186 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,987 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10013076 |
| Policy instance | 7 |
| Insurance contract or identification number | 10013076 | | Number of Individuals Covered | 2666 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $827,721 | | 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 | 094304 |
| Policy instance | 8 |
| Insurance contract or identification number | 094304 | | Number of Individuals Covered | 1103 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $41,778 | | Total amount of fees paid to insurance company | USD $3,461 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $259,809 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,778 | | Amount paid for insurance broker fees | 3461 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING, LLC |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 13 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 839 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $420,709 | | 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 | 8454713 |
| Policy instance | 12 |
| Insurance contract or identification number | 8454713 | | Number of Individuals Covered | 2710 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $240,497 | | Total amount of fees paid to insurance company | USD $31,543 | | Other welfare benefits provided | CRITICAL ILLNESS,GRP ACCIDENT, GRPH | | Welfare Benefit Premiums Paid to Carrier | USD $533,109 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $163,435 | | Amount paid for insurance broker fees | 28360 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 | | Insurance broker name | STEVEN RAY GRIFFIN |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35557 |
| Policy instance | 11 |
| Insurance contract or identification number | 35557 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $279,405 | | 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 | 604748 |
| Policy instance | 10 |
| Insurance contract or identification number | 604748 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $7,089 | | Total amount of fees paid to insurance company | USD $988 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $69,765 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,089 | | Amount paid for insurance broker fees | 988 | | Additional information about fees paid to insurance broker | ADDTL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008454713 |
| Policy instance | 9 |
| Insurance contract or identification number | 0008454713 | | Number of Individuals Covered | 1586 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $189,556 | | Total amount of fees paid to insurance company | USD $31,416 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VWB (ACCIDENT, ISTDPROTEC) | | Welfare Benefit Premiums Paid to Carrier | USD $465,295 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $126,859 | | Amount paid for insurance broker fees | 29228 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker name | THE PARTNERS GROUP |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 7978 |
| Policy instance | 1 |
| Insurance contract or identification number | 7978 | | Number of Individuals Covered | 389 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of fees paid to insurance company | USD $1,106 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,307,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1106 | | Additional information about fees paid to insurance broker | RETENTION BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094303 |
| Policy instance | 2 |
| Insurance contract or identification number | 094303 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $423 | | Total amount of fees paid to insurance company | USD $41 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $423 | | Amount paid for insurance broker fees | 41 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094302 |
| Policy instance | 3 |
| Insurance contract or identification number | 094302 | | Number of Individuals Covered | 425 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $5,939 | | Total amount of fees paid to insurance company | USD $1,098 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC. DEATH/DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $115,302 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,939 | | Amount paid for insurance broker fees | 1098 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 152178 |
| Policy instance | 4 |
| Insurance contract or identification number | 152178 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,619 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12288060 |
| Policy instance | 5 |
| Insurance contract or identification number | 12288060 | | Number of Individuals Covered | 1623 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $4,091 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,091 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 6 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 2134 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $17,181 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $922,472 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,181 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 7 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 795 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $451,964 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35557 |
| Policy instance | 12 |
| Insurance contract or identification number | 35557 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of fees paid to insurance company | USD $1,106 | | Welfare Benefit Premiums Paid to Carrier | USD $315,987 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1106 | | Additional information about fees paid to insurance broker | ADDTL COMP | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFIT PLANNING LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 604748 |
| Policy instance | 11 |
| Insurance contract or identification number | 604748 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $2,343 | | Total amount of fees paid to insurance company | USD $159 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,619 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,343 | | Amount paid for insurance broker fees | 159 | | Additional information about fees paid to insurance broker | ADDTL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008454713 |
| Policy instance | 10 |
| Insurance contract or identification number | 0008454713 | | Number of Individuals Covered | 980 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $52,735 | | Total amount of fees paid to insurance company | USD $15,459 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VWB (ACCIDENT, ISTDPROTEC) | | Welfare Benefit Premiums Paid to Carrier | USD $239,187 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $230 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1591 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker name | STEVEN RAY GRIFFIN |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0105361 |
| Policy instance | 9 |
| Insurance contract or identification number | R0105361 | | Number of Individuals Covered | 1096 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $29,783 | | Total amount of fees paid to insurance company | USD $3,021 | | Other welfare benefits provided | GCI EE PAY, GRP ACC VOL 11 | | Welfare Benefit Premiums Paid to Carrier | USD $185,597 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,382 | | Amount paid for insurance broker fees | 619 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | STEVEN RAY GRIFFIN |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10013076 |
| Policy instance | 8 |
| Insurance contract or identification number | 10013076 | | Number of Individuals Covered | 2281 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $582,771 | | 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 | 094303 |
| Policy instance | 2 |
| Insurance contract or identification number | 094303 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $490 | | Total amount of fees paid to insurance company | USD $37 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $490 | | Amount paid for insurance broker fees | 37 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094302 |
| Policy instance | 3 |
| Insurance contract or identification number | 094302 | | Number of Individuals Covered | 366 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $5,420 | | Total amount of fees paid to insurance company | USD $664 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC. DEATH/DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $88,493 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,420 | | Amount paid for insurance broker fees | 664 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 094304 |
| Policy instance | 4 |
| Insurance contract or identification number | 094304 | | Number of Individuals Covered | 907 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $30,463 | | Total amount of fees paid to insurance company | USD $1,523 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC. DEATH/DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $218,113 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,463 | | Amount paid for insurance broker fees | 1523 | | Additional information about fees paid to insurance broker | ADDITIONAL COMP | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12288060 |
| Policy instance | 5 |
| Insurance contract or identification number | 12288060 | | Number of Individuals Covered | 1427 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $3,887 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,887 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 6 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 1810 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $15,843 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,843 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 7978 |
| Policy instance | 1 |
| Insurance contract or identification number | 7978 | | Number of Individuals Covered | 414 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of fees paid to insurance company | USD $2,169 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,167,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2169 | | Additional information about fees paid to insurance broker | RETENTION BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10006377 |
| Policy instance | 7 |
| Insurance contract or identification number | 10006377 | | Number of Individuals Covered | 549 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Dental Insurance Welfare Benefit | Yes | | 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 | R0105361 |
| Policy instance | 9 |
| Insurance contract or identification number | R0105361 | | Number of Individuals Covered | 999 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $19,828 | | Total amount of fees paid to insurance company | USD $589 | | Other welfare benefits provided | GCI EE PAY, GRP ACC VOL 11 | | Welfare Benefit Premiums Paid to Carrier | USD $198,205 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,828 | | Amount paid for insurance broker fees | 589 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING, LLC |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008454713 |
| Policy instance | 10 |
| Insurance contract or identification number | 0008454713 | | Number of Individuals Covered | 650 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $19,297 | | Total amount of fees paid to insurance company | USD $1,337 | | Other welfare benefits provided | VWB (ACCIDENT, ISTDPROTEC) | | Welfare Benefit Premiums Paid to Carrier | USD $240,465 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $333 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1337 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker name | DAVIDSON BENEFITS PLANNING, LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 604748 |
| Policy instance | 11 |
| Insurance contract or identification number | 604748 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $2,069 | | Total amount of fees paid to insurance company | USD $252 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,434 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,069 | | Amount paid for insurance broker fees | 252 | | Additional information about fees paid to insurance broker | ADDTL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35557 |
| Policy instance | 12 |
| Insurance contract or identification number | 35557 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $265,372 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10013076 |
| Policy instance | 8 |
| Insurance contract or identification number | 10013076 | | Number of Individuals Covered | 1936 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $383,426 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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