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AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 401k Plan overview

Plan NameAMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN
Plan identification number 501

AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

AMERICA CHUNG NAM, LLC has sponsored the creation of one or more 401k plans.

Company Name:AMERICA CHUNG NAM, LLC
Employer identification number (EIN):330398523
NAIC Classification:424100

Additional information about AMERICA CHUNG NAM, LLC

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: 200815810215

More information about AMERICA CHUNG NAM, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-03-01
5012021-03-01SHUANG XU2022-09-02
5012020-03-01SHUANG XU2021-12-07
5012020-03-01SHUANG XU2022-09-02
5012019-03-01
5012018-08-01
5012017-08-01
5012016-08-01HERBERT HU
5012015-08-01JOHN WONG
5012014-08-01JOHN WONG
5012013-08-01JOHN WONG
5012012-08-01JOHN WONG
5012011-08-01JOHN WONG
5012010-08-01JOHN WONG
5012009-08-01JOHN WONG
5012008-08-01JOHN WONG
5012007-08-01JOHN WONG
5012006-08-01JOHN WONG

Plan Statistics for AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN

401k plan membership statisitcs for AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN

Measure Date Value
2022: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-03-01127
Total number of active participants reported on line 7a of the Form 55002022-03-01106
Total of all active and inactive participants2022-03-01106
Total participants2022-03-01106
2021: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-03-01129
Total number of active participants reported on line 7a of the Form 55002021-03-01127
Number of retired or separated participants receiving benefits2021-03-010
Number of other retired or separated participants entitled to future benefits2021-03-010
Total of all active and inactive participants2021-03-01127
Number of employers contributing to the scheme2021-03-010
2020: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-03-01135
Total number of active participants reported on line 7a of the Form 55002020-03-01128
Number of retired or separated participants receiving benefits2020-03-011
Number of other retired or separated participants entitled to future benefits2020-03-010
Total of all active and inactive participants2020-03-01129
Number of employers contributing to the scheme2020-03-010
2019: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-03-01158
Total number of active participants reported on line 7a of the Form 55002019-03-01146
Number of retired or separated participants receiving benefits2019-03-013
Number of other retired or separated participants entitled to future benefits2019-03-010
Total of all active and inactive participants2019-03-01149
2018: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-08-01199
Total number of active participants reported on line 7a of the Form 55002018-08-01183
Number of retired or separated participants receiving benefits2018-08-013
Number of other retired or separated participants entitled to future benefits2018-08-010
Total of all active and inactive participants2018-08-01186
2017: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-08-01143
Total number of active participants reported on line 7a of the Form 55002017-08-01156
Number of retired or separated participants receiving benefits2017-08-012
Number of other retired or separated participants entitled to future benefits2017-08-010
Total of all active and inactive participants2017-08-01158
2016: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-08-01153
Total number of active participants reported on line 7a of the Form 55002016-08-01142
Number of retired or separated participants receiving benefits2016-08-011
Number of other retired or separated participants entitled to future benefits2016-08-010
Total of all active and inactive participants2016-08-01143
2015: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-08-01150
Total number of active participants reported on line 7a of the Form 55002015-08-01153
Number of retired or separated participants receiving benefits2015-08-010
Number of other retired or separated participants entitled to future benefits2015-08-010
Total of all active and inactive participants2015-08-01153
2014: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-08-01162
Total number of active participants reported on line 7a of the Form 55002014-08-01161
Number of retired or separated participants receiving benefits2014-08-012
Number of other retired or separated participants entitled to future benefits2014-08-010
Total of all active and inactive participants2014-08-01163
2013: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-08-01160
Total number of active participants reported on line 7a of the Form 55002013-08-01161
Number of retired or separated participants receiving benefits2013-08-011
Number of other retired or separated participants entitled to future benefits2013-08-010
Total of all active and inactive participants2013-08-01162
2012: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-08-01150
Total number of active participants reported on line 7a of the Form 55002012-08-01160
Number of retired or separated participants receiving benefits2012-08-010
Number of other retired or separated participants entitled to future benefits2012-08-010
Total of all active and inactive participants2012-08-01160
2011: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-08-01155
Total number of active participants reported on line 7a of the Form 55002011-08-01150
Number of retired or separated participants receiving benefits2011-08-010
Number of other retired or separated participants entitled to future benefits2011-08-010
Total of all active and inactive participants2011-08-01150
2010: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-08-01138
Total number of active participants reported on line 7a of the Form 55002010-08-01155
Number of retired or separated participants receiving benefits2010-08-010
Number of other retired or separated participants entitled to future benefits2010-08-010
Total of all active and inactive participants2010-08-01155
2009: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-08-01122
Total number of active participants reported on line 7a of the Form 55002009-08-01138
Number of retired or separated participants receiving benefits2009-08-010
Number of other retired or separated participants entitled to future benefits2009-08-010
Total of all active and inactive participants2009-08-01138
2008: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year2008-08-01127
Total number of active participants reported on line 7a of the Form 55002008-08-01122
Number of retired or separated participants receiving benefits2008-08-010
Number of other retired or separated participants entitled to future benefits2008-08-010
Total of all active and inactive participants2008-08-01122
2007: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2007 401k membership
Total participants, beginning-of-year2007-08-01108
Total number of active participants reported on line 7a of the Form 55002007-08-01127
Number of retired or separated participants receiving benefits2007-08-010
Number of other retired or separated participants entitled to future benefits2007-08-010
Total of all active and inactive participants2007-08-01127
2006: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2006 401k membership
Total participants, beginning-of-year2006-08-01100
Total number of active participants reported on line 7a of the Form 55002006-08-01108
Number of retired or separated participants receiving benefits2006-08-010
Number of other retired or separated participants entitled to future benefits2006-08-010
Total of all active and inactive participants2006-08-01108

Form 5500 Responses for AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN

2022: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-03-01Type of plan entitySingle employer plan
2022-03-01Submission has been amendedNo
2022-03-01This submission is the final filingNo
2022-03-01This return/report is a short plan year return/report (less than 12 months)No
2022-03-01Plan is a collectively bargained planNo
2022-03-01Plan funding arrangement – InsuranceYes
2022-03-01Plan benefit arrangement – InsuranceYes
2021: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-03-01Type of plan entitySingle employer plan
2021-03-01Plan funding arrangement – InsuranceYes
2021-03-01Plan benefit arrangement – InsuranceYes
2020: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-03-01Type of plan entitySingle employer plan
2020-03-01Submission has been amendedYes
2020-03-01Plan funding arrangement – InsuranceYes
2020-03-01Plan benefit arrangement – InsuranceYes
2019: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-03-01Type of plan entitySingle employer plan
2019-03-01Submission has been amendedNo
2019-03-01This submission is the final filingNo
2019-03-01This return/report is a short plan year return/report (less than 12 months)No
2019-03-01Plan is a collectively bargained planNo
2019-03-01Plan funding arrangement – InsuranceYes
2019-03-01Plan funding arrangement – General assets of the sponsorYes
2019-03-01Plan benefit arrangement – InsuranceYes
2019-03-01Plan benefit arrangement – General assets of the sponsorYes
2018: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-08-01Type of plan entitySingle employer plan
2018-08-01Submission has been amendedNo
2018-08-01This submission is the final filingNo
2018-08-01This return/report is a short plan year return/report (less than 12 months)Yes
2018-08-01Plan is a collectively bargained planNo
2018-08-01Plan funding arrangement – InsuranceYes
2018-08-01Plan funding arrangement – General assets of the sponsorYes
2018-08-01Plan benefit arrangement – InsuranceYes
2018-08-01Plan benefit arrangement – General assets of the sponsorYes
2017: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-08-01Type of plan entitySingle employer plan
2017-08-01Submission has been amendedNo
2017-08-01This submission is the final filingNo
2017-08-01This return/report is a short plan year return/report (less than 12 months)No
2017-08-01Plan is a collectively bargained planNo
2017-08-01Plan funding arrangement – General assets of the sponsorYes
2017-08-01Plan benefit arrangement – InsuranceYes
2017-08-01Plan benefit arrangement – General assets of the sponsorYes
2016: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-08-01Type of plan entitySingle employer plan
2016-08-01Submission has been amendedNo
2016-08-01This submission is the final filingNo
2016-08-01This return/report is a short plan year return/report (less than 12 months)No
2016-08-01Plan is a collectively bargained planNo
2016-08-01Plan funding arrangement – InsuranceYes
2016-08-01Plan benefit arrangement – InsuranceYes
2015: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-08-01Type of plan entitySingle employer plan
2015-08-01Submission has been amendedNo
2015-08-01This submission is the final filingNo
2015-08-01This return/report is a short plan year return/report (less than 12 months)No
2015-08-01Plan is a collectively bargained planNo
2015-08-01Plan funding arrangement – InsuranceYes
2015-08-01Plan benefit arrangement – InsuranceYes
2014: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-08-01Type of plan entitySingle employer plan
2014-08-01Submission has been amendedNo
2014-08-01This submission is the final filingNo
2014-08-01This return/report is a short plan year return/report (less than 12 months)No
2014-08-01Plan is a collectively bargained planNo
2014-08-01Plan funding arrangement – General assets of the sponsorYes
2014-08-01Plan benefit arrangement – InsuranceYes
2013: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-08-01Type of plan entitySingle employer plan
2013-08-01Submission has been amendedNo
2013-08-01This submission is the final filingNo
2013-08-01This return/report is a short plan year return/report (less than 12 months)No
2013-08-01Plan is a collectively bargained planNo
2013-08-01Plan funding arrangement – General assets of the sponsorYes
2013-08-01Plan benefit arrangement – InsuranceYes
2012: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-08-01Type of plan entitySingle employer plan
2012-08-01Submission has been amendedNo
2012-08-01This submission is the final filingNo
2012-08-01This return/report is a short plan year return/report (less than 12 months)No
2012-08-01Plan is a collectively bargained planNo
2012-08-01Plan funding arrangement – InsuranceYes
2012-08-01Plan benefit arrangement – InsuranceYes
2011: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-08-01Type of plan entitySingle employer plan
2011-08-01Submission has been amendedNo
2011-08-01This submission is the final filingNo
2011-08-01This return/report is a short plan year return/report (less than 12 months)No
2011-08-01Plan is a collectively bargained planNo
2011-08-01Plan funding arrangement – InsuranceYes
2011-08-01Plan benefit arrangement – InsuranceYes
2010: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-08-01Type of plan entitySingle employer plan
2010-08-01Submission has been amendedNo
2010-08-01This submission is the final filingNo
2010-08-01This return/report is a short plan year return/report (less than 12 months)No
2010-08-01Plan is a collectively bargained planNo
2010-08-01Plan funding arrangement – InsuranceYes
2010-08-01Plan benefit arrangement – InsuranceYes
2009: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-08-01Type of plan entitySingle employer plan
2009-08-01Submission has been amendedNo
2009-08-01This submission is the final filingNo
2009-08-01This return/report is a short plan year return/report (less than 12 months)No
2009-08-01Plan is a collectively bargained planNo
2009-08-01Plan funding arrangement – InsuranceYes
2009-08-01Plan benefit arrangement – InsuranceYes
2008: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2008 form 5500 responses
2008-08-01Type of plan entitySingle employer plan
2008-08-01Submission has been amendedNo
2008-08-01This submission is the final filingNo
2008-08-01This return/report is a short plan year return/report (less than 12 months)No
2008-08-01Plan is a collectively bargained planNo
2008-08-01Plan funding arrangement – InsuranceYes
2008-08-01Plan benefit arrangement – InsuranceYes
2007: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2007 form 5500 responses
2007-08-01Type of plan entitySingle employer plan
2007-08-01Submission has been amendedNo
2007-08-01This submission is the final filingNo
2007-08-01This return/report is a short plan year return/report (less than 12 months)No
2007-08-01Plan is a collectively bargained planNo
2007-08-01Plan funding arrangement – InsuranceYes
2007-08-01Plan benefit arrangement – InsuranceYes
2006: AMERICA CHUNG NAM, LLC WELFARE BENEFIT PLAN 2006 form 5500 responses
2006-08-01Type of plan entitySingle employer plan
2006-08-01First time form 5500 has been submittedYes
2006-08-01Submission has been amendedNo
2006-08-01This submission is the final filingNo
2006-08-01This return/report is a short plan year return/report (less than 12 months)No
2006-08-01Plan is a collectively bargained planNo
2006-08-01Plan funding arrangement – InsuranceYes
2006-08-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number282302
Policy instance 1
Insurance contract or identification number282302
Number of Individuals Covered106
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $32,547
Total amount of fees paid to insurance companyUSD $21,809
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 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 DISBURSEMENT
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 $925,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number282302
Policy instance 1
Insurance contract or identification number282302
Number of Individuals Covered127
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $42,145
Total amount of fees paid to insurance companyUSD $5,028
Health Insurance Welfare BenefitYes
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 $940,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,820
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number282302
Policy instance 1
Insurance contract or identification number282302
Number of Individuals Covered183
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $32,246
Total amount of fees paid to insurance companyUSD $17,195
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $973,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,049
Amount paid for insurance broker fees17195
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number282302
Policy instance 1
Insurance contract or identification number282302
Number of Individuals Covered204
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $1,285
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 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 $21,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,285
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00529282
Policy instance 2
Insurance contract or identification number00529282
Number of Individuals Covered72
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $2,818
Total amount of fees paid to insurance companyUSD $1,547
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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, ACCIDENT, OPTIONAL LIFE/AD&D, VOL. CRITICAL ILLNESS, AND VOLUNTARY HOSPITAL INDEMNITY
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $32,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,818
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number282302
Policy instance 3
Insurance contract or identification number282302
Number of Individuals Covered207
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $24,702
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 $718,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,702
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )
Policy contract numberER28316
Policy instance 3
Insurance contract or identification numberER28316
Number of Individuals Covered102
Insurance policy start date2018-08-01
Insurance policy end date2019-02-28
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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, CANCER, CRITICAL ILLNESS
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?Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00529282
Policy instance 2
Insurance contract or identification number00529282
Number of Individuals Covered94
Insurance policy start date2018-08-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $3,129
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 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 $33,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,129
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
RIVERSTONE CAPITAL (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberPRM191
Policy instance 1
Insurance contract or identification numberPRM191
Number of Individuals Covered156
Insurance policy start date2018-08-01
Insurance policy end date2019-02-28
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
RIVERSTONE CAPITAL (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberPRM191
Policy instance 1
Insurance contract or identification numberPRM191
Number of Individuals Covered156
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $82,245
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 $834,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00529282
Policy instance 2
Insurance contract or identification number00529282
Number of Individuals Covered97
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $6,143
Total amount of fees paid to insurance companyUSD $2,941
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 $65,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )
Policy contract numberER28316
Policy instance 3
Insurance contract or identification numberER28316
Number of Individuals Covered102
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $7,282
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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D/CANCER/CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4310363
Policy instance 2
Insurance contract or identification numberE4310363
Number of Individuals Covered36
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $9,265
Total amount of fees paid to insurance companyUSD $1,102
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 BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $25,360
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,009
Insurance broker organization code?3
Amount paid for insurance broker fees380
Additional information about fees paid to insurance brokerFEES
Insurance broker nameMICHELLE RENE PAYNE
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166368
Policy instance 1
Insurance contract or identification number166368
Number of Individuals Covered231
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $39,576
Total amount of fees paid to insurance companyUSD $19,503
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 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
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 $1,025,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,254
Insurance broker organization code?3
Amount paid for insurance broker fees19503
Additional information about fees paid to insurance brokerFEES
Insurance broker nameCENTERSTONE INS. AND FIN. SVCS.
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number166368
Policy instance 2
Insurance contract or identification number166368
Number of Individuals Covered161
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $1,235
Total amount of fees paid to insurance companyUSD $500
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 $23,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,235
Insurance broker organization code?3
Amount paid for insurance broker fees500
Additional information about fees paid to insurance brokerBONUS, OVERRIDE AND NON MONETARY COMPENSATION
Insurance broker nameCENTERSTONE INSURANCE & FIN. SVCS.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4310363
Policy instance 3
Insurance contract or identification numberE4310363
Number of Individuals Covered55
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $9,703
Total amount of fees paid to insurance companyUSD $2,971
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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY BENEFITS
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 $17,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,335
Amount paid for insurance broker fees482
Additional information about fees paid to insurance brokerBONUS COMMISSIONS
Insurance broker organization code?3
Insurance broker nameEVELYN GARCIA
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166368
Policy instance 4
Insurance contract or identification number166368
Number of Individuals Covered160
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $43,874
Total amount of fees paid to insurance companyUSD $17,760
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 $852,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,874
Insurance broker organization code?3
Amount paid for insurance broker fees17760
Additional information about fees paid to insurance brokerBONUS, OVERRIDE AND NON MONETARY COMPENSATION
Insurance broker nameCENTERSTONE INSURANCE & FIN. SVCS.
PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )
Policy contract number15868
Policy instance 1
Insurance contract or identification number15868
Number of Individuals Covered156
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $6,762
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 $80,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,663
Insurance broker organization code?3
Insurance broker nameLEAVITT INSURANCE SERVICES
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number166368
Policy instance 2
Insurance contract or identification number166368
Number of Individuals Covered52
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $878
Total amount of fees paid to insurance companyUSD $351
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 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 $16,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $878
Insurance broker organization code?3
Amount paid for insurance broker fees351
Additional information about fees paid to insurance brokerBONUS, OVERRIDE AND NON MONETARY COMPENSATION
Insurance broker nameCENTERSTONE INSURANCE & FIN. SVCS.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166368
Policy instance 1
Insurance contract or identification number166368
Number of Individuals Covered161
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $46,631
Total amount of fees paid to insurance companyUSD $18,629
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 $886,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $46,631
Insurance broker organization code?3
Amount paid for insurance broker fees18629
Additional information about fees paid to insurance brokerBONUS, OVERRIDE AND NON MONETARY COMPENSATION
Insurance broker nameCENTERSTONE INSURANCE & FIN. SVCS.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166368
Policy instance 2
Insurance contract or identification number166368
Number of Individuals Covered192
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $37,613
Total amount of fees paid to insurance companyUSD $12,123
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 $709,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,613
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameCENTERSTONE INS & FINANCIAL SVCS
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number166368
Policy instance 1
Insurance contract or identification number166368
Number of Individuals Covered203
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $5,692
Total amount of fees paid to insurance companyUSD $1,835
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 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
Welfare Benefit Premiums Paid to CarrierUSD $107,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,692
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameCENTERSTONE INS. & FINANCIAL SVCS.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166368
Policy instance 2
Insurance contract or identification number166368
Number of Individuals Covered184
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $4,899
Total amount of fees paid to insurance companyUSD $1,839
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 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
Welfare Benefit Premiums Paid to CarrierUSD $95,962
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 number166368
Policy instance 1
Insurance contract or identification number166368
Number of Individuals Covered179
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $36,425
Total amount of fees paid to insurance companyUSD $13,672
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 $713,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number3332020
Policy instance 2
Insurance contract or identification number3332020
Number of Individuals Covered155
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $6,280
Total amount of fees paid to insurance companyUSD $2,517
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 $63,741
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 number166368
Policy instance 1
Insurance contract or identification number166368
Number of Individuals Covered175
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $20,292
Total amount of fees paid to insurance companyUSD $7,690
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 $658,950
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 number166368
Policy instance 1
Insurance contract or identification number166368
Number of Individuals Covered159
Insurance policy start date2009-08-01
Insurance policy end date2010-07-31
Total amount of commissions paid to insurance brokerUSD $26,129
Total amount of fees paid to insurance companyUSD $10,452
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 $529,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,129
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameCENTERSTONE INS. & FIN. SERVICES
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number3332020
Policy instance 2
Insurance contract or identification number3332020
Number of Individuals Covered138
Insurance policy start date2009-08-01
Insurance policy end date2010-07-31
Total amount of commissions paid to insurance brokerUSD $4,625
Total amount of fees paid to insurance companyUSD $1,850
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 $46,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,625
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameCENTERSTONE INS. & FIN. SERVICES
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberH54566, 943850
Policy instance 1
Insurance contract or identification numberH54566, 943850
Number of Individuals Covered0
Insurance policy start date2008-08-01
Insurance policy end date2009-07-31
Total amount of commissions paid to insurance brokerUSD $9
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 $178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameTANTIWASADAKRAN ZHUANG
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number419244
Policy instance 2
Insurance contract or identification number419244
Number of Individuals Covered11
Insurance policy start date2008-08-01
Insurance policy end date2009-07-31
Total amount of commissions paid to insurance brokerUSD $5,442
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 $53,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,368
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameWILLNER-CARDINET-KIDWELL
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166368
Policy instance 3
Insurance contract or identification number166368
Number of Individuals Covered122
Insurance policy start date2008-08-01
Insurance policy end date2009-07-31
Total amount of commissions paid to insurance brokerUSD $23,299
Total amount of fees paid to insurance companyUSD $9,320
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 $465,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,299
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameCENTERSTONE INS & FIN SERVICES
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberH54566, 843850
Policy instance 1
Insurance contract or identification numberH54566, 843850
Number of Individuals Covered140
Insurance policy start date2007-08-01
Insurance policy end date2008-07-31
Total amount of commissions paid to insurance brokerUSD $22,277
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 $445,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,277
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameTANTIWASADAKRAN ZHUANG
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number419244
Policy instance 2
Insurance contract or identification number419244
Number of Individuals Covered117
Insurance policy start date2007-08-01
Insurance policy end date2008-07-31
Total amount of commissions paid to insurance brokerUSD $4,508
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 $43,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,363
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameWILLNER-CARDINET-KIDWELL
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberH54566, 943850
Policy instance 1
Insurance contract or identification numberH54566, 943850
Number of Individuals Covered121
Insurance policy start date2006-08-01
Insurance policy end date2007-07-31
Total amount of commissions paid to insurance brokerUSD $19,787
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 $395,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,787
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameDONALD W TAPERT INS AGENCY INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number419244
Policy instance 2
Insurance contract or identification number419244
Number of Individuals Covered99
Insurance policy start date2006-11-01
Insurance policy end date2007-07-31
Total amount of commissions paid to insurance brokerUSD $2,733
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 $26,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,018
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameWILLNER-CARDINET-KIDWELL

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