CLARE FOUNDATION INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CLARE MATRIX HEALTH AND WELFARE PLAN
Measure | Date | Value |
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2022: CLARE MATRIX HEALTH AND WELFARE PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 108 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 89 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 89 |
2021: CLARE MATRIX HEALTH AND WELFARE PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-01-01 | 134 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 109 |
Number of retired or separated participants receiving benefits | 2021-01-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
Total of all active and inactive participants | 2021-01-01 | 110 |
2020: CLARE MATRIX HEALTH AND WELFARE PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 154 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 131 |
Number of retired or separated participants receiving benefits | 2020-01-01 | 3 |
Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
Total of all active and inactive participants | 2020-01-01 | 134 |
2019: CLARE MATRIX HEALTH AND WELFARE PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-04-01 | 157 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-04-01 | 153 |
Number of retired or separated participants receiving benefits | 2019-04-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2019-04-01 | 0 |
Total of all active and inactive participants | 2019-04-01 | 154 |
2022: CLARE MATRIX HEALTH AND WELFARE PLAN 2022 form 5500 responses |
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2022-01-01 | Type of plan entity | Single employer plan |
2022-01-01 | Submission has been amended | No |
2022-01-01 | This submission is the final filing | No |
2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2022-01-01 | Plan is a collectively bargained plan | No |
2022-01-01 | Plan funding arrangement – Insurance | Yes |
2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-01-01 | Plan benefit arrangement – Insurance | Yes |
2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: CLARE MATRIX HEALTH AND WELFARE PLAN 2021 form 5500 responses |
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2021-01-01 | Type of plan entity | Single employer plan |
2021-01-01 | Submission has been amended | No |
2021-01-01 | This submission is the final filing | No |
2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-01-01 | Plan is a collectively bargained plan | No |
2021-01-01 | Plan funding arrangement – Insurance | Yes |
2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-01-01 | Plan benefit arrangement – Insurance | Yes |
2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: CLARE MATRIX HEALTH AND WELFARE PLAN 2020 form 5500 responses |
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2020-01-01 | Type of plan entity | Single employer plan |
2020-01-01 | Submission has been amended | No |
2020-01-01 | This submission is the final filing | No |
2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-01-01 | Plan is a collectively bargained plan | No |
2020-01-01 | Plan funding arrangement – Insurance | Yes |
2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-01-01 | Plan benefit arrangement – Insurance | Yes |
2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: CLARE MATRIX HEALTH AND WELFARE PLAN 2019 form 5500 responses |
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2019-04-01 | Type of plan entity | Single employer plan |
2019-04-01 | First time form 5500 has been submitted | Yes |
2019-04-01 | Submission has been amended | No |
2019-04-01 | This submission is the final filing | No |
2019-04-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2019-04-01 | Plan is a collectively bargained plan | No |
2019-04-01 | Plan funding arrangement – Insurance | Yes |
2019-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-04-01 | Plan benefit arrangement – Insurance | Yes |
2019-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 240130 |
Policy instance | 6 |
Insurance contract or identification number | 240130 | Number of Individuals Covered | 28 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $650 | Total amount of fees paid to insurance company | USD $127 | 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 | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS | 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 $4,724 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $520 | Amount paid for insurance broker fees | 75 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 240129 |
Policy instance | 5 |
Insurance contract or identification number | 240129 | Number of Individuals Covered | 34 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $471 | Total amount of fees paid to insurance company | USD $112 | 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 | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT | 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 $2,451 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $377 | Amount paid for insurance broker fees | 75 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 110665 |
Policy instance | 4 |
Insurance contract or identification number | 110665 | Number of Individuals Covered | 24 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $9,282 | 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 $270,663 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,282 | Insurance broker organization code? | 3 |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 282296 |
Policy instance | 3 |
Insurance contract or identification number | 282296 | Number of Individuals Covered | 57 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $35,134 | 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 $582,438 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $35,134 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 240131 |
Policy instance | 2 |
Insurance contract or identification number | 240131 | Number of Individuals Covered | 34 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $1,199 | Total amount of fees paid to insurance company | USD $171 | 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 | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | HOSPITAL INDEMNITY | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $7,624 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $959 | Amount paid for insurance broker fees | 75 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
Policy contract number | 282296 |
Policy instance | 1 |
Insurance contract or identification number | 282296 | Number of Individuals Covered | 89 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $5,788 | 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 | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $95,952 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,788 | Insurance broker organization code? | 3 |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 282296 |
Policy instance | 4 |
Insurance contract or identification number | 282296 | Number of Individuals Covered | 66 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $44,260 | Total amount of fees paid to insurance company | USD $1,184 | 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 $749,911 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $44,260 | Amount paid for insurance broker fees | 1184 | Additional information about fees paid to insurance broker | OTHER FEES | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 110665 |
Policy instance | 3 |
Insurance contract or identification number | 110665 | Number of Individuals Covered | 38 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $17,744 | 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 $331,566 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,744 | Insurance broker organization code? | 3 |
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CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
Policy contract number | 25450 |
Policy instance | 2 |
Insurance contract or identification number | 25450 | Number of Individuals Covered | 59 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $2,046 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS AND HOSPITAL INDEMBITY | 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 $17,378 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $823 | Insurance broker organization code? | 3 |
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ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
Policy contract number | 282296 |
Policy instance | 1 |
Insurance contract or identification number | 282296 | Number of Individuals Covered | 108 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $6,287 | Total amount of fees paid to insurance company | USD $168 | 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 | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $106,522 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,287 | Amount paid for insurance broker fees | 168 | Additional information about fees paid to insurance broker | OTHER FEES | Insurance broker organization code? | 3 |
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ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
Policy contract number | 282296 |
Policy instance | 4 |
Insurance contract or identification number | 282296 | Number of Individuals Covered | 133 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $3,596 | Total amount of fees paid to insurance company | USD $206 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $65,022 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,596 | Amount paid for insurance broker fees | 206 | Additional information about fees paid to insurance broker | OTHER FEES | Insurance broker organization code? | 3 |
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CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
Policy contract number | 25450 |
Policy instance | 3 |
Insurance contract or identification number | 25450 | Number of Individuals Covered | 28 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $13,296 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS AND HOSPITAL INDEMBITY | 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 $13,296 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,321 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 110665 |
Policy instance | 2 |
Insurance contract or identification number | 110665 | Number of Individuals Covered | 54 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $19,082 | 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 $410,132 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $19,082 | Insurance broker organization code? | 3 |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 282296 |
Policy instance | 1 |
Insurance contract or identification number | 282296 | Number of Individuals Covered | 117 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $36,074 | Total amount of fees paid to insurance company | USD $2,070 | 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 | 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 $652,248 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $36,074 | Amount paid for insurance broker fees | 2070 | Additional information about fees paid to insurance broker | OTHER FEES | Insurance broker organization code? | 3 |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 282296 |
Policy instance | 4 |
Insurance contract or identification number | 282296 | Number of Individuals Covered | 127 | Insurance policy start date | 2019-04-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $18,746 | 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 | 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 $305,953 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $18,746 | Insurance broker organization code? | 3 |
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CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
Policy contract number | 25450 |
Policy instance | 3 |
Insurance contract or identification number | 25450 | Number of Individuals Covered | 55 | Insurance policy start date | 2019-04-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,295 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS AND HOSPITAL INDEMBITY | 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 $2,397 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $518 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 110665 |
Policy instance | 2 |
Insurance contract or identification number | 110665 | Number of Individuals Covered | 68 | Insurance policy start date | 2019-04-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $18,715 | 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 $358,226 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,293 | Insurance broker organization code? | 3 |
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ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
Policy contract number | 282296 |
Policy instance | 1 |
Insurance contract or identification number | 282296 | Number of Individuals Covered | 152 | Insurance policy start date | 2019-04-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $2,040 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $33,299 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,040 | Insurance broker organization code? | 3 |
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