SAFRAN PASSENGER INNOVATIONS LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN
401k plan membership statisitcs for SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2019: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 364 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 0 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 0 |
| 2018: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 349 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 364 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 10 |
| Total of all active and inactive participants | 2018-09-01 | 380 |
| 2017: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-09-01 | 313 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 349 |
| Number of retired or separated participants receiving benefits | 2017-09-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 5 |
| Total of all active and inactive participants | 2017-09-01 | 361 |
| 2016: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-09-01 | 277 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 313 |
| Number of retired or separated participants receiving benefits | 2016-09-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-09-01 | 3 |
| Total of all active and inactive participants | 2016-09-01 | 318 |
| Total participants, beginning-of-year | 2016-06-01 | 272 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 277 |
| Number of retired or separated participants receiving benefits | 2016-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-06-01 | 8 |
| Total of all active and inactive participants | 2016-06-01 | 287 |
| 2015: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-01 | 213 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 263 |
| Number of retired or separated participants receiving benefits | 2015-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 0 |
| Total of all active and inactive participants | 2015-06-01 | 263 |
| 2014: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-06-01 | 234 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-06-01 | 255 |
| Number of retired or separated participants receiving benefits | 2014-06-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2014-06-01 | 0 |
| Total of all active and inactive participants | 2014-06-01 | 260 |
| 2013: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-01 | 261 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 227 |
| Number of retired or separated participants receiving benefits | 2013-06-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 0 |
| Total of all active and inactive participants | 2013-06-01 | 234 |
| 2012: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-06-01 | 187 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 259 |
| Number of retired or separated participants receiving benefits | 2012-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2012-06-01 | 0 |
| Total of all active and inactive participants | 2012-06-01 | 261 |
| 2019: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | Yes |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | Submission has been amended | No |
| 2018-09-01 | This submission is the final filing | No |
| 2018-09-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2018-09-01 | Plan is a collectively bargained plan | No |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Submission has been amended | No |
| 2017-09-01 | This submission is the final filing | No |
| 2017-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-09-01 | Plan is a collectively bargained plan | No |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-09-01 | Type of plan entity | Single employer plan |
| 2016-09-01 | Submission has been amended | No |
| 2016-09-01 | This submission is the final filing | No |
| 2016-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-09-01 | Plan is a collectively bargained plan | No |
| 2016-09-01 | Plan funding arrangement – Insurance | Yes |
| 2016-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016-06-01 | Type of plan entity | Single employer plan |
| 2016-06-01 | Submission has been amended | No |
| 2016-06-01 | This submission is the final filing | No |
| 2016-06-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2016-06-01 | Plan is a collectively bargained plan | No |
| 2016-06-01 | Plan funding arrangement – Insurance | Yes |
| 2016-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-06-01 | Type of plan entity | Single employer plan |
| 2015-06-01 | Submission has been amended | No |
| 2015-06-01 | This submission is the final filing | No |
| 2015-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-06-01 | Plan is a collectively bargained plan | No |
| 2015-06-01 | Plan funding arrangement – Insurance | Yes |
| 2015-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-06-01 | Type of plan entity | Single employer plan |
| 2014-06-01 | Submission has been amended | No |
| 2014-06-01 | This submission is the final filing | No |
| 2014-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-06-01 | Plan is a collectively bargained plan | No |
| 2014-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-06-01 | Type of plan entity | Single employer plan |
| 2013-06-01 | Submission has been amended | No |
| 2013-06-01 | This submission is the final filing | No |
| 2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-06-01 | Plan is a collectively bargained plan | No |
| 2013-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: SYSTEMS & SOFTWARE ENTERPRISES, LLC DBA ZODIAC INFLIGHT INNOVATIONS EMPLOYEE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-06-01 | Type of plan entity | Single employer plan |
| 2012-06-01 | Submission has been amended | No |
| 2012-06-01 | This submission is the final filing | No |
| 2012-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-06-01 | Plan is a collectively bargained plan | No |
| 2012-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4202347 |
| Policy instance | 5 |
| Insurance contract or identification number | E4202347 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,043 | | Total amount of fees paid to insurance company | USD $268 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,124 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,043 | | Amount paid for insurance broker fees | 268 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 661707 |
| Policy instance | 4 |
| Insurance contract or identification number | 661707 | | Number of Individuals Covered | 387 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $17,990 | | Total amount of fees paid to insurance company | USD $4,261 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,831 | | Amount paid for insurance broker fees | 2226 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 228889 |
| Policy instance | 3 |
| Insurance contract or identification number | 228889 | | Number of Individuals Covered | 366 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $65,103 | | 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 $1,651,203 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $65,103 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 276584 |
| Policy instance | 2 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 392 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $104,598 | | Total amount of fees paid to insurance company | USD $51,124 | | 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 | Yes | | 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 $1,584,665 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $104,598 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 51124 | | Additional information about fees paid to insurance broker | FEES |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276584 |
| Policy instance | 1 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 392 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $104,598 | | Total amount of fees paid to insurance company | USD $51,124 | | 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 $2,443,229 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $104,598 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 51124 | | Additional information about fees paid to insurance broker | FEES |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 276584 |
| Policy instance | 2 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 352 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | 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 | Yes | | 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 | SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D, AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $489,725 | | 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 | 228889 |
| Policy instance | 3 |
| Insurance contract or identification number | 228889 | | Number of Individuals Covered | 309 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $19,384 | | 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 $508,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,384 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276584 |
| Policy instance | 1 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $33,509 | | Total amount of fees paid to insurance company | USD $17,504 | | 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 $326,169 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,509 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 17504 | | Additional information about fees paid to insurance broker | FEES |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 661707 |
| Policy instance | 4 |
| Insurance contract or identification number | 661707 | | Number of Individuals Covered | 344 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,566 | | Total amount of fees paid to insurance company | USD $845 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,751 | | Amount paid for insurance broker fees | 441 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 276584 |
| Policy instance | 2 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 342 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $83,580 | | Total amount of fees paid to insurance company | USD $43,065 | | 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 | Yes | | 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 | SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D, AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,310,291 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,785 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 43065 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | ROMERO & LEVIN INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 228889 |
| Policy instance | 3 |
| Insurance contract or identification number | 228889 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $46,023 | | 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 $1,260,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,984 | | Insurance broker organization code? | 3 | | Insurance broker name | ROMERO & LEVIN WEALTH MANAGEMENT |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 661707 |
| Policy instance | 4 |
| Insurance contract or identification number | 661707 | | Number of Individuals Covered | 349 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $17,631 | | Total amount of fees paid to insurance company | USD $4,052 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,655 | | Amount paid for insurance broker fees | 2128 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | MULROY INSURANCE AGENCY LLC |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276584 |
| Policy instance | 1 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | 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 $938,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 661707 |
| Policy instance | 4 |
| Insurance contract or identification number | 661707 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $3,333 | | Total amount of fees paid to insurance company | USD $709 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,636 | | Amount paid for insurance broker fees | 378 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | MULROY INSURANCE AGENCY LLC |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 276584 |
| Policy instance | 3 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 281 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2016-08-31 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, SUPPLEMENTAL LIFE, SUPPLEMENTAL AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $23,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276584 |
| Policy instance | 2 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $17,326 | | Total amount of fees paid to insurance company | USD $8,826 | | 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 | 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 $394,460 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,326 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 8826 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | WARNER PACIFIC INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 228889 |
| Policy instance | 1 |
| Insurance contract or identification number | 228889 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $7,833 | | 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 $200,003 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,833 | | Insurance broker organization code? | 3 | | Insurance broker name | ROMERO & LEVIN WEALTH MANAGEMENT |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 661707 |
| Policy instance | 4 |
| Insurance contract or identification number | 661707 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $14,669 | | Total amount of fees paid to insurance company | USD $3,092 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,466 | | Amount paid for insurance broker fees | 1955 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | MULROY INSURANCE AGENCY LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 228889 |
| Policy instance | 3 |
| Insurance contract or identification number | 228889 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $27,328 | | 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 $740,497 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,328 | | Insurance broker organization code? | 3 | | Insurance broker name | ROMERO & LEVIN WEALTH MANAGEMENT |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276584 |
| Policy instance | 2 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | 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 $769,024 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 276584 |
| Policy instance | 1 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $69,455 | | Total amount of fees paid to insurance company | USD $35,676 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, SUPPLEMENTAL LIFE, SUPPLEMENTAL AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $973,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $69,455 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 35676 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | WARNER PACIFIC INSURANCE SERVICES |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 661707 |
| Policy instance | 3 |
| Insurance contract or identification number | 661707 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $9,583 | | Total amount of fees paid to insurance company | USD $1,913 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,583 | | Amount paid for insurance broker fees | 1913 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN MUTUAL |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276584 |
| Policy instance | 2 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $55,270 | | Total amount of fees paid to insurance company | USD $29,676 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | 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 $1,371,722 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $55,270 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 29676 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | WARNER PACIFIC INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 228889 |
| Policy instance | 1 |
| Insurance contract or identification number | 228889 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $21,444 | | 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 $539,687 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,444 | | Insurance broker organization code? | 3 | | Insurance broker name | ROMERO & LEVIN WEALTH MANAGEMENT |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276584 |
| Policy instance | 2 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $47,018 | | Total amount of fees paid to insurance company | USD $25,305 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | 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 $1,143,110 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $47,018 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 25305 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | WARNER PACIFIC INSURANCE SERVICES |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 663496 |
| Policy instance | 3 |
| Insurance contract or identification number | 663496 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $3,165 | | Total amount of fees paid to insurance company | USD $671 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,165 | | Amount paid for insurance broker fees | 671 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN MUTUAL |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 663496 |
| Policy instance | 4 |
| Insurance contract or identification number | 663496 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $2,228 | | Total amount of fees paid to insurance company | USD $472 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,228 | | Amount paid for insurance broker fees | 472 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN MUTUAL |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 663496 |
| Policy instance | 5 |
| Insurance contract or identification number | 663496 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $1,326 | | Total amount of fees paid to insurance company | USD $281 | | 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 | Yes | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,326 | | Amount paid for insurance broker fees | 281 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN MUTUAL |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 228889 |
| Policy instance | 6 |
| Insurance contract or identification number | 228889 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $16,046 | | 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 $394,432 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,046 | | Insurance broker organization code? | 3 | | Insurance broker name | ROMERO & LEVIN WEALTH MANAGEMENT |
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| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 663496 |
| Policy instance | 1 |
| Insurance contract or identification number | 663496 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $954 | | Total amount of fees paid to insurance company | USD $202 | | 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 | Yes | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $954 | | Amount paid for insurance broker fees | 202 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN MUTUAL |
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| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276584 |
| Policy instance | 2 |
| Insurance contract or identification number | 276584 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $52,060 | | Total amount of fees paid to insurance company | USD $24,010 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | 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 $1,187,225 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $52,060 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 24010 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | WARNER PACIFIC INSURANCE SERVICES |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 228889 |
| Policy instance | 3 |
| Insurance contract or identification number | 228889 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $11,617 | | 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 $296,153 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,040 | | Insurance broker organization code? | 3 | | Insurance broker name | A.J. LONGO & ASSOCIATES |
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| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 661707 |
| Policy instance | 1 |
| Insurance contract or identification number | 661707 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $4,085 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $53,866 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,064 | | Insurance broker organization code? | 3 | | Insurance broker name | NONIE DE SURRA |
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