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EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan NameEIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN
Plan identification number 501

EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

EIBACH, INC. has sponsored the creation of one or more 401k plans.

Company Name:EIBACH, INC.
Employer identification number (EIN):330276266
NAIC Classification:332610

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-04-01
5012021-04-01
5012020-04-01
5012019-04-01STEPHANIE DAVISON2020-09-08
5012018-04-01STEPHANIE DAVISON2019-09-20
5012017-04-01
5012016-04-01STEPHANIE DAVISON STEPHANIE DAVISON2018-01-12
5012015-04-01GREG COOLEY GREG COOLEY2016-10-13
5012014-04-01GREG COOLEY
5012013-04-01GREG COOLEY

Plan Statistics for EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-04-01116
Total number of active participants reported on line 7a of the Form 55002022-04-01113
Number of retired or separated participants receiving benefits2022-04-011
Number of other retired or separated participants entitled to future benefits2022-04-010
Total of all active and inactive participants2022-04-01114
2021: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-04-01117
Total number of active participants reported on line 7a of the Form 55002021-04-01119
Number of retired or separated participants receiving benefits2021-04-011
Number of other retired or separated participants entitled to future benefits2021-04-010
Total of all active and inactive participants2021-04-01120
2020: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-04-01111
Total number of active participants reported on line 7a of the Form 55002020-04-01113
Number of retired or separated participants receiving benefits2020-04-010
Number of other retired or separated participants entitled to future benefits2020-04-010
Total of all active and inactive participants2020-04-01113
2019: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-04-01124
Total number of active participants reported on line 7a of the Form 55002019-04-01126
Number of retired or separated participants receiving benefits2019-04-010
Number of other retired or separated participants entitled to future benefits2019-04-010
Total of all active and inactive participants2019-04-01126
Number of employers contributing to the scheme2019-04-010
2018: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-04-01117
Total number of active participants reported on line 7a of the Form 55002018-04-01124
Number of retired or separated participants receiving benefits2018-04-010
Number of other retired or separated participants entitled to future benefits2018-04-010
Total of all active and inactive participants2018-04-01124
Number of employers contributing to the scheme2018-04-010
2017: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-04-01117
Total number of active participants reported on line 7a of the Form 55002017-04-01117
Number of retired or separated participants receiving benefits2017-04-010
Number of other retired or separated participants entitled to future benefits2017-04-010
Total of all active and inactive participants2017-04-01117
2016: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-04-01101
Total number of active participants reported on line 7a of the Form 55002016-04-01104
Number of retired or separated participants receiving benefits2016-04-010
Number of other retired or separated participants entitled to future benefits2016-04-010
Total of all active and inactive participants2016-04-01104
2015: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-04-01103
Total number of active participants reported on line 7a of the Form 55002015-04-01101
Number of retired or separated participants receiving benefits2015-04-010
Number of other retired or separated participants entitled to future benefits2015-04-010
Total of all active and inactive participants2015-04-01101
2014: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-04-01105
Total number of active participants reported on line 7a of the Form 55002014-04-01102
Number of retired or separated participants receiving benefits2014-04-011
Number of other retired or separated participants entitled to future benefits2014-04-010
Total of all active and inactive participants2014-04-01103
2013: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-04-01104
Total number of active participants reported on line 7a of the Form 55002013-04-01104
Number of retired or separated participants receiving benefits2013-04-011
Number of other retired or separated participants entitled to future benefits2013-04-010
Total of all active and inactive participants2013-04-01105

Form 5500 Responses for EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN

2022: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-04-01Type of plan entitySingle employer plan
2022-04-01Submission has been amendedNo
2022-04-01This submission is the final filingNo
2022-04-01This return/report is a short plan year return/report (less than 12 months)No
2022-04-01Plan is a collectively bargained planNo
2022-04-01Plan funding arrangement – InsuranceYes
2022-04-01Plan funding arrangement – General assets of the sponsorYes
2022-04-01Plan benefit arrangement – InsuranceYes
2022-04-01Plan benefit arrangement – General assets of the sponsorYes
2021: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-04-01Type of plan entitySingle employer plan
2021-04-01Submission has been amendedNo
2021-04-01This submission is the final filingNo
2021-04-01This return/report is a short plan year return/report (less than 12 months)No
2021-04-01Plan is a collectively bargained planNo
2021-04-01Plan funding arrangement – InsuranceYes
2021-04-01Plan funding arrangement – General assets of the sponsorYes
2021-04-01Plan benefit arrangement – InsuranceYes
2021-04-01Plan benefit arrangement – General assets of the sponsorYes
2020: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-04-01Type of plan entitySingle employer plan
2020-04-01Submission has been amendedNo
2020-04-01This submission is the final filingNo
2020-04-01This return/report is a short plan year return/report (less than 12 months)No
2020-04-01Plan is a collectively bargained planNo
2020-04-01Plan funding arrangement – InsuranceYes
2020-04-01Plan funding arrangement – General assets of the sponsorYes
2020-04-01Plan benefit arrangement – InsuranceYes
2020-04-01Plan benefit arrangement – General assets of the sponsorYes
2019: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-04-01Type of plan entitySingle employer plan
2019-04-01Plan funding arrangement – InsuranceYes
2019-04-01Plan funding arrangement – General assets of the sponsorYes
2019-04-01Plan benefit arrangement – InsuranceYes
2019-04-01Plan benefit arrangement – General assets of the sponsorYes
2018: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-04-01Type of plan entitySingle employer plan
2018-04-01Plan funding arrangement – InsuranceYes
2018-04-01Plan funding arrangement – General assets of the sponsorYes
2018-04-01Plan benefit arrangement – InsuranceYes
2018-04-01Plan benefit arrangement – General assets of the sponsorYes
2017: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-04-01Type of plan entitySingle employer plan
2017-04-01Plan funding arrangement – InsuranceYes
2017-04-01Plan funding arrangement – General assets of the sponsorYes
2017-04-01Plan benefit arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – General assets of the sponsorYes
2016: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Submission has been amendedNo
2016-04-01This submission is the final filingNo
2016-04-01This return/report is a short plan year return/report (less than 12 months)No
2016-04-01Plan is a collectively bargained planNo
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan funding arrangement – General assets of the sponsorYes
2016-04-01Plan benefit arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – General assets of the sponsorYes
2015: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)No
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – General assets of the sponsorYes
2015-04-01Plan benefit arrangement – InsuranceYes
2014: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-04-01Type of plan entitySingle employer plan
2014-04-01Submission has been amendedNo
2014-04-01This submission is the final filingNo
2014-04-01This return/report is a short plan year return/report (less than 12 months)No
2014-04-01Plan is a collectively bargained planNo
2014-04-01Plan funding arrangement – General assets of the sponsorYes
2014-04-01Plan benefit arrangement – InsuranceYes
2013: EIBACH SPRINGS INC. EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-04-01Type of plan entitySingle employer plan
2013-04-01First time form 5500 has been submittedYes
2013-04-01Submission has been amendedNo
2013-04-01This submission is the final filingNo
2013-04-01This return/report is a short plan year return/report (less than 12 months)No
2013-04-01Plan is a collectively bargained planNo
2013-04-01Plan funding arrangement – General assets of the sponsorYes
2013-04-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00585385
Policy instance 3
Insurance contract or identification number00585385
Number of Individuals Covered115
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $25,609
Total amount of fees paid to insurance companyUSD $6,085
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $121,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,528
Amount paid for insurance broker fees6085
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number228809
Policy instance 2
Insurance contract or identification number228809
Number of Individuals Covered200
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $64,417
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,229,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $64,417
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number261104
Policy instance 1
Insurance contract or identification number261104
Number of Individuals Covered109
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $15,013
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $109,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,029
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00585385
Policy instance 3
Insurance contract or identification number00585385
Number of Individuals Covered127
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $17,028
Total amount of fees paid to insurance companyUSD $4,057
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $99,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,122
Amount paid for insurance broker fees4057
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number228809
Policy instance 2
Insurance contract or identification number228809
Number of Individuals Covered121
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $50,151
Total amount of fees paid to insurance companyUSD $2,156
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,094,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $50,151
Amount paid for insurance broker fees3
Additional information about fees paid to insurance brokerVALUE OF NON-MONETARY COMPENSATION
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number261104
Policy instance 1
Insurance contract or identification number261104
Number of Individuals Covered74
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $6,269
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,627
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberH7E91
Policy instance 1
Insurance contract or identification numberH7E91
Number of Individuals Covered45
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $7,257
Total amount of fees paid to insurance companyUSD $497
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $40,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,731
Amount paid for insurance broker fees425
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number228809
Policy instance 2
Insurance contract or identification number228809
Number of Individuals Covered207
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $50,780
Total amount of fees paid to insurance companyUSD $266
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,014,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,602
Amount paid for insurance broker fees266
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
CALIFORNIA DENTAL NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number003583
Policy instance 3
Insurance contract or identification number003583
Number of Individuals Covered71
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $1,851
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $18,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,362
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number165596
Policy instance 4
Insurance contract or identification number165596
Number of Individuals Covered31
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $2,656
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 BrokerUSD $1,731
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number165596
Policy instance 5
Insurance contract or identification number165596
Number of Individuals Covered71
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $1,118
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 BrokerUSD $679
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number165596
Policy instance 6
Insurance contract or identification number165596
Number of Individuals Covered104
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $989
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 BrokerUSD $686
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number165596
Policy instance 3
Insurance contract or identification number165596
Number of Individuals Covered126
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $4,178
Total amount of fees paid to insurance companyUSD $1,771
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,178
Amount paid for insurance broker fees1771
Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number228809
Policy instance 2
Insurance contract or identification number228809
Number of Individuals Covered225
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $49,471
Total amount of fees paid to insurance companyUSD $1,736
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $991,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,471
Amount paid for insurance broker fees1736
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberH7E91
Policy instance 1
Insurance contract or identification numberH7E91
Number of Individuals Covered56
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $8,062
Total amount of fees paid to insurance companyUSD $613
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $35,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,535
Amount paid for insurance broker fees510
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number228809
Policy instance 3
Insurance contract or identification number228809
Number of Individuals Covered211
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $51,980
Total amount of fees paid to insurance companyUSD $1,941
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $978,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,980
Amount paid for insurance broker fees1941
Additional information about fees paid to insurance brokerBONUS, NON-MONETARY COMPENSATION
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number154072
Policy instance 2
Insurance contract or identification number154072
Number of Individuals Covered207
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $4,945
Total amount of fees paid to insurance companyUSD $1,296
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $73,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,359
Amount paid for insurance broker fees1296
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberH7E91
Policy instance 1
Insurance contract or identification numberH7E91
Number of Individuals Covered56
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $7,564
Total amount of fees paid to insurance companyUSD $174
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $26,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,755
Amount paid for insurance broker fees124
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number228809
Policy instance 3
Insurance contract or identification number228809
Number of Individuals Covered183
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $38,169
Total amount of fees paid to insurance companyUSD $10
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $811,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,164
Amount paid for insurance broker fees10
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameMILESTONE INSURANCE BROKERS, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number154072
Policy instance 2
Insurance contract or identification number154072
Number of Individuals Covered177
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $4,913
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $71,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,913
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberH7E91
Policy instance 1
Insurance contract or identification numberH7E91
Number of Individuals Covered37
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $3,626
Total amount of fees paid to insurance companyUSD $244
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $19,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $785
Amount paid for insurance broker fees174
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameMARIAN LENCIONI
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number154072
Policy instance 1
Insurance contract or identification number154072
Number of Individuals Covered101
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $1,364
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $18,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,277
Insurance broker organization code?3
Insurance broker nameBILL M. ROLLINS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number228809
Policy instance 2
Insurance contract or identification number228809
Number of Individuals Covered191
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $38,819
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $774,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,680
Insurance broker organization code?3
Insurance broker nameBILL ROLLINS
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number154072
Policy instance 3
Insurance contract or identification number154072
Number of Individuals Covered89
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $3,041
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $40,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,846
Insurance broker organization code?3
Insurance broker nameBILL M. ROLLINS
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number154072
Policy instance 3
Insurance contract or identification number154072
Number of Individuals Covered102
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $859
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $7,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $859
Insurance broker organization code?3
Insurance broker nameBILL M. ROLLINS
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number154072
Policy instance 2
Insurance contract or identification number154072
Number of Individuals Covered92
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $3,565
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $32,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,565
Insurance broker organization code?3
Insurance broker nameBILL M. ROLLINS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number228809
Policy instance 1
Insurance contract or identification number228809
Number of Individuals Covered187
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $36,543
Total amount of fees paid to insurance companyUSD $3,000
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $756,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,543
Amount paid for insurance broker fees3000
Additional information about fees paid to insurance brokerBONUS COMMISSIONS
Insurance broker organization code?3
Insurance broker nameBILL M. ROLLINS
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number154072
Policy instance 2
Insurance contract or identification number154072
Number of Individuals Covered96
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $14,917
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $325,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,917
Insurance broker organization code?3
Insurance broker nameBILL M. ROLLINS
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number228809
Policy instance 3
Insurance contract or identification number228809
Number of Individuals Covered113
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $20,869
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $424,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,869
Insurance broker organization code?3
Insurance broker nameBILL M. ROLLINS
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number154072
Policy instance 1
Insurance contract or identification number154072
Number of Individuals Covered104
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $514
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $11,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $514
Insurance broker organization code?3
Insurance broker nameBILL M. ROLLINS

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