METIS TPS, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan METIS TPS, LLC HEALTH AND WELFARE PLAN
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | L6758A |
| Policy instance | 2 |
| Insurance contract or identification number | L6758A | | Number of Individuals Covered | 265 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $61,231 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,229,896 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,231 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| CALIFORNIA DENTAL NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 002494 |
| Policy instance | 6 |
| Insurance contract or identification number | 002494 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $1,425 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,248 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,425 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97902621001 |
| Policy instance | 5 |
| Insurance contract or identification number | 97902621001 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $1,293 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,818 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,293 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1036134 |
| Policy instance | 4 |
| Insurance contract or identification number | 1036134 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $3,429 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,656 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,429 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| HOLMAN FAMILY COUNSELING, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 16041 |
| Policy instance | 3 |
| Insurance contract or identification number | 16041 | | Number of Individuals Covered | 472 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $525 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $5,253 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $525 | | Amount paid for insurance broker fees | 0 | | 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 | 230763 |
| Policy instance | 7 |
| Insurance contract or identification number | 230763 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $26,953 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $544,354 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,953 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 873524G |
| Policy instance | 1 |
| Insurance contract or identification number | 873524G | | Number of Individuals Covered | 466 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $1,139 | | Total amount of fees paid to insurance company | USD $104 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,931 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,139 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
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| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 873524G |
| Policy instance | 1 |
| Insurance contract or identification number | 873524G | | Number of Individuals Covered | 430 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,085 | | Total amount of fees paid to insurance company | USD $228 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,233 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,085 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | L6758A |
| Policy instance | 2 |
| Insurance contract or identification number | L6758A | | Number of Individuals Covered | 241 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $54,396 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,094,183 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,396 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| HOLMAN FAMILY COUNSELING, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 16041 |
| Policy instance | 3 |
| Insurance contract or identification number | 16041 | | Number of Individuals Covered | 434 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $496 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $4,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $496 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | UNKNOWN |
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| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1036134 |
| Policy instance | 4 |
| Insurance contract or identification number | 1036134 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $3,400 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,627 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,400 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97902621001 |
| Policy instance | 5 |
| Insurance contract or identification number | 97902621001 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,463 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,832 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,463 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| CALIFORNIA DENTAL NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 002494 |
| Policy instance | 6 |
| Insurance contract or identification number | 002494 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,618 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,179 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,618 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230763 |
| Policy instance | 7 |
| Insurance contract or identification number | 230763 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $22,355 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $486,590 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,355 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| HOLMAN FAMILY COUNSELING, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 16041 |
| Policy instance | 7 |
| Insurance contract or identification number | 16041 | | Number of Individuals Covered | 352 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $392 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | 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 $3,918 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $392 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 873524G |
| Policy instance | 6 |
| Insurance contract or identification number | 873524G | | Number of Individuals Covered | 350 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $780 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND 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 $5,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $780 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9790262 |
| Policy instance | 5 |
| Insurance contract or identification number | 9790262 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $1,010 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,010 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| CALIFORNIA DENTAL NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 2494 |
| Policy instance | 4 |
| Insurance contract or identification number | 2494 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $653 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,531 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $653 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1036134 |
| Policy instance | 3 |
| Insurance contract or identification number | 1036134 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $2,798 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26,087 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,671 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230763 |
| Policy instance | 2 |
| Insurance contract or identification number | 230763 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $11,064 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $228,358 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,064 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | L6758 ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | L6758 ET AL | | Number of Individuals Covered | 199 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $41,640 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $834,058 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,640 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| HOLMAN FAMILY COUNSELING, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 16041 |
| Policy instance | 7 |
| Insurance contract or identification number | 16041 | | Number of Individuals Covered | 292 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $344 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | 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 $5,164 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $344 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 873524G |
| Policy instance | 6 |
| Insurance contract or identification number | 873524G | | Number of Individuals Covered | 297 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $762 | | Total amount of fees paid to insurance company | USD $47 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND 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 $5,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $762 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 47 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9790262 |
| Policy instance | 5 |
| Insurance contract or identification number | 9790262 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $1,141 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,943 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,141 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| CALIFORNIA DENTAL NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 2494 |
| Policy instance | 4 |
| Insurance contract or identification number | 2494 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $618 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $618 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1036134 |
| Policy instance | 3 |
| Insurance contract or identification number | 1036134 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $2,287 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,768 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,266 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230763 |
| Policy instance | 2 |
| Insurance contract or identification number | 230763 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $9,157 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $198,602 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,157 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | L6758 ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | L6758 ET AL | | Number of Individuals Covered | 193 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $38,637 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $776,364 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,637 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230763 |
| Policy instance | 7 |
| Insurance contract or identification number | 230763 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $8,955 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $179,378 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,006 | | Insurance broker organization code? | 3 | | Insurance broker name | GNW-EVERGREEN INSURANCE SERVICES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9790262 |
| Policy instance | 5 |
| Insurance contract or identification number | 9790262 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $621 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,893 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $621 | | Insurance broker organization code? | 3 | | Insurance broker name | GNW-EVERGREEN INSURANCE SERVICES |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 873524G |
| Policy instance | 4 |
| Insurance contract or identification number | 873524G | | Number of Individuals Covered | 274 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $700 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 $4,627 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $414 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1036134 |
| Policy instance | 3 |
| Insurance contract or identification number | 1036134 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $1,395 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $788 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL |
|
| HOLMAN FAMILY COUNSELING, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 16041 |
| Policy instance | 2 |
| Insurance contract or identification number | 16041 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $318 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | 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 $3,183 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $162 | | Insurance broker organization code? | 3 | | Insurance broker name | GNW-EVERGREEN INSURANCE SERVICES |
|
| CALIFORNIA DENTAL NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 002494 |
| Policy instance | 1 |
| Insurance contract or identification number | 002494 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $969 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,694 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $672 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | S1212/L6758 |
| Policy instance | 6 |
| Insurance contract or identification number | S1212/L6758 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $37,266 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $751,237 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,706 | | Insurance broker organization code? | 3 | | Insurance broker name | GNW-EVERGREEN INSURANCE SERVICES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9790262 |
| Policy instance | 2 |
| Insurance contract or identification number | 9790262 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $747 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,369 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $747 | | Insurance broker organization code? | 3 | | Insurance broker name | GNW-EVERGREEN INSURANCE SERVICES |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5452564 |
| Policy instance | 3 |
| Insurance contract or identification number | 5452564 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $1,339 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 $8,927 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,339 | | Insurance broker organization code? | 3 | | Insurance broker name | GNW-EVERGREEN INSURANCE SERVICES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9829722 |
| Policy instance | 4 |
| Insurance contract or identification number | 9829722 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $7 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $71 | | 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 | | Insurance broker organization code? | 3 | | Insurance broker name | GNW-EVERGREEN INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230763 |
| Policy instance | 1 |
| Insurance contract or identification number | 230763 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $8,072 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $161,689 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,072 | | Insurance broker organization code? | 3 | | Insurance broker name | GNW-EVERGREEN INSURANCE SERVICES |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | S1212/L6758 |
| Policy instance | 5 |
| Insurance contract or identification number | S1212/L6758 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $34,696 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $696,420 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,696 | | Insurance broker organization code? | 3 | | Insurance broker name | GNW-EVERGREEN INSURANCE SERVICES |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276541 |
| Policy instance | 6 |
| Insurance contract or identification number | 276541 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $2,710 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26,478 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,710 | | Insurance broker organization code? | 3 | | Insurance broker name | GNW-EVERGREEN INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230763 |
| Policy instance | 4 |
| Insurance contract or identification number | 230763 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $8,142 | | Total amount of fees paid to insurance company | USD $1,540 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $143,559 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9790262 |
| Policy instance | 5 |
| Insurance contract or identification number | 9790262 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $859 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,475 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 352681 |
| Policy instance | 1 |
| Insurance contract or identification number | 352681 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $55 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,280 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276541 |
| Policy instance | 2 |
| Insurance contract or identification number | 276541 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $2,817 | | Total amount of fees paid to insurance company | USD $310 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $29,814 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5452564 |
| Policy instance | 6 |
| Insurance contract or identification number | 5452564 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $1,332 | | Total amount of fees paid to insurance company | USD $87 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 $8,877 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | S1212/L6758 |
| Policy instance | 3 |
| Insurance contract or identification number | S1212/L6758 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $30,684 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $625,624 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230763 |
| Policy instance | 4 |
| Insurance contract or identification number | 230763 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $5,891 | | Total amount of fees paid to insurance company | USD $675 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $121,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 352681 |
| Policy instance | 2 |
| Insurance contract or identification number | 352681 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $32,757 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $655,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NP6834 |
| Policy instance | 1 |
| Insurance contract or identification number | NP6834 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $2,799 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,707 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9790262 |
| Policy instance | 5 |
| Insurance contract or identification number | 9790262 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $809 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,867 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5452564 |
| Policy instance | 3 |
| Insurance contract or identification number | 5452564 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $1,261 | | Total amount of fees paid to insurance company | USD $357 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 $8,409 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
