PSEB LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PSEB LLC HEALTH AND WELFARE BENEFITS PLAN
| HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 ) |
| Policy contract number | 55075 |
| Policy instance | 1 |
| Insurance contract or identification number | 55075 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $1,087 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $75,237 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,087 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 802480 |
| Policy instance | 6 |
| Insurance contract or identification number | 802480 | | Number of Individuals Covered | 431 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $36,671 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $148,514 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,671 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 9902453 |
| Policy instance | 5 |
| Insurance contract or identification number | 9902453 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $25,872 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0003792 |
| Policy instance | 4 |
| Insurance contract or identification number | SP0003792 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $2,912 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | TELEHEALTH,TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $58,243 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,912 | | 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: 64548 ) |
| Policy contract number | FLX980108 |
| Policy instance | 6 |
| Insurance contract or identification number | FLX980108 | | Number of Individuals Covered | 2416 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $169,601 | | Total amount of fees paid to insurance company | USD $16,285 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $1,112,391 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $169,601 | | Amount paid for insurance broker fees | 16285 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
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| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 802480 |
| Policy instance | 5 |
| Insurance contract or identification number | 802480 | | Number of Individuals Covered | 431 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $36,671 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $148,514 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,671 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 9902453 |
| Policy instance | 4 |
| Insurance contract or identification number | 9902453 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $25,872 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 2083400 |
| Policy instance | 3 |
| Insurance contract or identification number | 2083400 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | 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 $62,641 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 234900 |
| Policy instance | 2 |
| Insurance contract or identification number | 234900 | | Number of Individuals Covered | 42 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $936 | | Total amount of fees paid to insurance company | USD $3,850 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $205,948 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $936 | | Amount paid for insurance broker fees | 3850 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX980108 |
| Policy instance | 7 |
| Insurance contract or identification number | FLX980108 | | Number of Individuals Covered | 2416 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $169,601 | | Total amount of fees paid to insurance company | USD $16,285 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $1,112,391 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $169,601 | | Amount paid for insurance broker fees | 16285 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
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