R AND C MOTOR CORPORATION DBA CLAREMONT TOYOTA has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CLAREMONT TOYOTA FLEXIBLE BENEFIT PLAN
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 56178 |
| Policy instance | 3 |
| Insurance contract or identification number | 56178 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2020-05-17 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 3340911 |
| Policy instance | 2 |
| Insurance contract or identification number | 3340911 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2020-05-17 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231609 |
| Policy instance | 1 |
| Insurance contract or identification number | 231609 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2020-05-17 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | FLX967897 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX967897 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2020-05-17 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 231609 |
| Policy instance | 7 |
| Insurance contract or identification number | 231609 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $23,739 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $900,243 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,739 | | Insurance broker organization code? | 3 |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK969389 |
| Policy instance | 2 |
| Insurance contract or identification number | OK969389 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $102 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMEBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,022 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $102 | | Insurance broker organization code? | 3 |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967897 |
| Policy instance | 3 |
| Insurance contract or identification number | FLX967897 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $760 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,596 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $760 | | Insurance broker organization code? | 3 |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3340911 |
| Policy instance | 4 |
| Insurance contract or identification number | 3340911 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $5,475 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $55,226 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,475 | | Insurance broker organization code? | 3 |
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| CIGNA DENTAL HEALTH OF CALIFORNIA,INC (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 3340911 |
| Policy instance | 5 |
| Insurance contract or identification number | 3340911 | | Number of Individuals Covered | 84 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $1,280 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $12,800 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,280 | | Insurance broker organization code? | 3 |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 56178 |
| Policy instance | 6 |
| Insurance contract or identification number | 56178 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $9,374 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT CANCER, CRITICAL ILLNESS, ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $109,724 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,966 | | Insurance broker organization code? | 3 |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 92408 |
| Policy instance | 1 |
| Insurance contract or identification number | 92408 | | Number of Individuals Covered | 89 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $2,678 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, 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 Carrier | USD $49,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,701 | | Insurance broker organization code? | 3 |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 56178 |
| Policy instance | 3 |
| Insurance contract or identification number | 56178 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $11,226 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $153,389 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,063 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967897 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX967897 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $798 | | Total amount of fees paid to insurance company | USD $443 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,980 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $798 | | Amount paid for insurance broker fees | 443 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 231609 |
| Policy instance | 1 |
| Insurance contract or identification number | 231609 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $25,035 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,032,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,035 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3340911 |
| Policy instance | 2 |
| Insurance contract or identification number | 3340911 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $5,018 | | Total amount of fees paid to insurance company | USD $915 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,581 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,018 | | Amount paid for insurance broker fees | 915 | | Insurance broker organization code? | 3 |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967897 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX967897 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $763 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,625 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $763 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 56178 |
| Policy instance | 3 |
| Insurance contract or identification number | 56178 | | Number of Individuals Covered | 69 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $14,404 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $153,786 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,111 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | B & G PENSION AND INS SVCS INC |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3340911 |
| Policy instance | 2 |
| Insurance contract or identification number | 3340911 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $4,894 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $49,357 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,894 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 231609 |
| Policy instance | 1 |
| Insurance contract or identification number | 231609 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $24,885 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $923,241 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,885 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 512023 |
| Policy instance | 2 |
| Insurance contract or identification number | 512023 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $3,518 | | Total amount of fees paid to insurance company | USD $642 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $57,481 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,518 | | Amount paid for insurance broker fees | 642 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 56178/92408 |
| Policy instance | 3 |
| Insurance contract or identification number | 56178/92408 | | Number of Individuals Covered | 65 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $14,348 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CANCER | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $130,982 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,088 | | Insurance broker organization code? | 3 | | Insurance broker name | B AND G PENSION AND INS. SVCS, INC. |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 231609 |
| Policy instance | 1 |
| Insurance contract or identification number | 231609 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $24,203 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $925,639 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,203 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05999623 |
| Policy instance | 2 |
| Insurance contract or identification number | KM05999623 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $1,624 | | Total amount of fees paid to insurance company | USD $336 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $33,991 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,624 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 336 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 56178/92408 |
| Policy instance | 5 |
| Insurance contract or identification number | 56178/92408 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $11,798 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT CANCER | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $125,860 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,703 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10141683 |
| Policy instance | 4 |
| Insurance contract or identification number | 10141683 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $866 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,662 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $866 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | KM05999623 |
| Policy instance | 3 |
| Insurance contract or identification number | KM05999623 | | Number of Individuals Covered | 280 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $1,152 | | Total amount of fees paid to insurance company | USD $182 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,207 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,152 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 182 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 231609 |
| Policy instance | 1 |
| Insurance contract or identification number | 231609 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $31,082 | | Total amount of fees paid to insurance company | USD $7,355 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,206,937 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,082 | | Amount paid for insurance broker fees | 7355 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 231609 |
| Policy instance | 2 |
| Insurance contract or identification number | 231609 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $26,274 | | Total amount of fees paid to insurance company | USD $5,000 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,051,811 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,274 | | Amount paid for insurance broker fees | 5000 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10141683 |
| Policy instance | 3 |
| Insurance contract or identification number | 10141683 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $777 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,772 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $777 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05999623 |
| Policy instance | 4 |
| Insurance contract or identification number | KM05999623 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $1,339 | | Total amount of fees paid to insurance company | USD $466 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26,777 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,339 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 466 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | KM05999623 |
| Policy instance | 5 |
| Insurance contract or identification number | KM05999623 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $1,144 | | Total amount of fees paid to insurance company | USD $382 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,892 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,144 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 382 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 231609 |
| Policy instance | 1 |
| Insurance contract or identification number | 231609 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $26,274 | | Total amount of fees paid to insurance company | USD $5,000 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,051,811 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,274 | | Amount paid for insurance broker fees | 5000 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05999623 |
| Policy instance | 2 |
| Insurance contract or identification number | KM05999623 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $1,339 | | Total amount of fees paid to insurance company | USD $466 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26,777 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,339 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 466 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | KM05999623 |
| Policy instance | 3 |
| Insurance contract or identification number | KM05999623 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $1,144 | | Total amount of fees paid to insurance company | USD $382 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,892 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,144 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 382 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10141683 |
| Policy instance | 4 |
| Insurance contract or identification number | 10141683 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $777 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,772 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $777 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 56178/92408 |
| Policy instance | 5 |
| Insurance contract or identification number | 56178/92408 | | Number of Individuals Covered | 68 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $13,678 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT CANCER | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $129,902 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,297 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 56178/92408 |
| Policy instance | 1 |
| Insurance contract or identification number | 56178/92408 | | Number of Individuals Covered | 68 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $13,678 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT CANCER | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $129,902 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,297 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | CANCER |
| Policy instance | 2 |
| Insurance contract or identification number | CANCER | | Number of Individuals Covered | 60 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $1,912 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,597 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,341 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN FIDELITY ASSURANCE COMPANY |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | ACCIDENT ONLY |
| Policy instance | 8 |
| Insurance contract or identification number | ACCIDENT ONLY | | Number of Individuals Covered | 65 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $2,799 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT ONLY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,375 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,469 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN FIDELITY ASSURANCE COMPANY |
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| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | 76083,L6507,N46 |
| Policy instance | 1 |
| Insurance contract or identification number | 76083,L6507,N46 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $59,921 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,210,169 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $59,921 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10141683 |
| Policy instance | 7 |
| Insurance contract or identification number | 10141683 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $592 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $571 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INS CENTER |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276449 |
| Policy instance | 6 |
| Insurance contract or identification number | 276449 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $4,411 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $44,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,411 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | STD |
| Policy instance | 5 |
| Insurance contract or identification number | STD | | Number of Individuals Covered | 1 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $39 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN FIDELITY ASSURANCE COMPANY |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | LTD |
| Policy instance | 4 |
| Insurance contract or identification number | LTD | | Number of Individuals Covered | 87 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $6,570 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $93,907 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,695 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN FIDELITY ASSURANCE COMPANY |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | HI |
| Policy instance | 3 |
| Insurance contract or identification number | HI | | Number of Individuals Covered | 3 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $44 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,476 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | 76083,L6507,N46 |
| Policy instance | 1 |
| Insurance contract or identification number | 76083,L6507,N46 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $56,583 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,128,633 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | ACCIDENT ONLY |
| Policy instance | 8 |
| Insurance contract or identification number | ACCIDENT ONLY | | Number of Individuals Covered | 70 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $1,835 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT ONLY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10141683 |
| Policy instance | 7 |
| Insurance contract or identification number | 10141683 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $597 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,970 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276449 |
| Policy instance | 6 |
| Insurance contract or identification number | 276449 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $2,903 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $37,162 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | STD |
| Policy instance | 5 |
| Insurance contract or identification number | STD | | Number of Individuals Covered | 1 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $31 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | LTD |
| Policy instance | 4 |
| Insurance contract or identification number | LTD | | Number of Individuals Covered | 88 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $8,243 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $81,741 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | HI |
| Policy instance | 3 |
| Insurance contract or identification number | HI | | Number of Individuals Covered | 4 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $54 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,795 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | CANCER |
| Policy instance | 2 |
| Insurance contract or identification number | CANCER | | Number of Individuals Covered | 61 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $1,432 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,837 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | CANCER |
| Policy instance | 7 |
| Insurance contract or identification number | CANCER | | Number of Individuals Covered | 30 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $1,190 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,722 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,190 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 7821DA |
| Policy instance | 4 |
| Insurance contract or identification number | 7821DA | | Number of Individuals Covered | 2 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $123 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ORTHODONTIA | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $123 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | LTD |
| Policy instance | 10 |
| Insurance contract or identification number | LTD | | Number of Individuals Covered | 108 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $3,713 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $74,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,713 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | 76083,L6507,N46 |
| Policy instance | 1 |
| Insurance contract or identification number | 76083,L6507,N46 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $53,284 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,103,837 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,284 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | STD |
| Policy instance | 2 |
| Insurance contract or identification number | STD | | Number of Individuals Covered | 1 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $45 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
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| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 7821DB |
| Policy instance | 3 |
| Insurance contract or identification number | 7821DB | | Number of Individuals Covered | 59 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $1,417 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ORTHODONTIA | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,142 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,417 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | HOSPITAL-INDEMN |
| Policy instance | 9 |
| Insurance contract or identification number | HOSPITAL-INDEMN | | Number of Individuals Covered | 3 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $64 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | ACCIDENT ONLY |
| Policy instance | 8 |
| Insurance contract or identification number | ACCIDENT ONLY | | Number of Individuals Covered | 53 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $1,320 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT ONLY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,530 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,320 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 093704 |
| Policy instance | 6 |
| Insurance contract or identification number | 093704 | | Number of Individuals Covered | 212 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $800 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,437 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $800 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
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| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NP7821 |
| Policy instance | 5 |
| Insurance contract or identification number | NP7821 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $1,666 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ORTHODONTIA | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,190 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,666 | | Insurance broker organization code? | 3 | | Insurance broker name | B&G PENSION AND INSURANCE SERVICES |
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