CAPITOL INDEMNITY CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN
401k plan membership statisitcs for CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | W12267 |
Policy instance | 2 |
Insurance contract or identification number | W12267 | Number of Individuals Covered | 366 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $20,559 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,758,044 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,559 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 1754 |
Policy instance | 1 |
Insurance contract or identification number | 1754 | Number of Individuals Covered | 183 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $19,044 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,484,850 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $19,044 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5944742 |
Policy instance | 3 |
Insurance contract or identification number | 5944742 | Number of Individuals Covered | 876 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $6,082 | Total amount of fees paid to insurance company | USD $5,080 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $250,223 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,082 | Amount paid for insurance broker fees | 87 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30039791 |
Policy instance | 4 |
Insurance contract or identification number | 30039791 | Number of Individuals Covered | 211 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $1,445 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $35,423 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,445 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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EMPATHIA, INC. (National Association of Insurance Commissioners NAIC id number: 62419 ) |
Policy contract number | 00 |
Policy instance | 5 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 309 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $6,588 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
Policy contract number | 724599 |
Policy instance | 6 |
Insurance contract or identification number | 724599 | Number of Individuals Covered | 162 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $10,132 | Total amount of fees paid to insurance company | USD $1,793 | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $47,419 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,484 | Amount paid for insurance broker fees | 1793 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | GL162916 |
Policy instance | 7 |
Insurance contract or identification number | GL162916 | Number of Individuals Covered | 293 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $11,880 | Total amount of fees paid to insurance company | USD $2,785 | 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 | Welfare Benefit Premiums Paid to Carrier | USD $214,098 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,880 | Amount paid for insurance broker fees | 2783 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | Insurance broker organization code? | 3 |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 1754 |
Policy instance | 1 |
Insurance contract or identification number | 1754 | Number of Individuals Covered | 179 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $20,714 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,327,139 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,714 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30039791 |
Policy instance | 4 |
Insurance contract or identification number | 30039791 | Number of Individuals Covered | 210 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $1,533 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $35,333 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,533 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05944742 |
Policy instance | 3 |
Insurance contract or identification number | KM05944742 | Number of Individuals Covered | 917 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $4,899 | Total amount of fees paid to insurance company | USD $2,482 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $183,824 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,899 | Amount paid for insurance broker fees | 71 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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EMPATHIA, INC. (National Association of Insurance Commissioners NAIC id number: 62419 ) |
Policy contract number | 000 |
Policy instance | 5 |
Insurance contract or identification number | 000 | Number of Individuals Covered | 300 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $6,588 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | GL162916 |
Policy instance | 6 |
Insurance contract or identification number | GL162916 | Number of Individuals Covered | 293 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $11,952 | Total amount of fees paid to insurance company | USD $8,321 | 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 | Welfare Benefit Premiums Paid to Carrier | USD $222,649 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,952 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | W12267 |
Policy instance | 2 |
Insurance contract or identification number | W12267 | Number of Individuals Covered | 362 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $20,317 | Total amount of fees paid to insurance company | USD $4,068 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,753,269 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,317 | Amount paid for insurance broker fees | 4068 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0ASLP |
Policy instance | 6 |
Insurance contract or identification number | GLUG0ASLP | Number of Individuals Covered | 299 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-11-30 | Total amount of commissions paid to insurance broker | USD $16,308 | Total amount of fees paid to insurance company | USD $6,534 | 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 | Welfare Benefit Premiums Paid to Carrier | USD $202,017 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $16,308 | Amount paid for insurance broker fees | 6534 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | GL162916 |
Policy instance | 5 |
Insurance contract or identification number | GL162916 | Number of Individuals Covered | 293 | Insurance policy start date | 2020-12-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | 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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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30039791 |
Policy instance | 4 |
Insurance contract or identification number | 30039791 | Number of Individuals Covered | 208 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $1,588 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $33,360 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,588 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 1754 |
Policy instance | 1 |
Insurance contract or identification number | 1754 | Number of Individuals Covered | 228 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $18,672 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,486,017 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $18,672 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | W12267 |
Policy instance | 2 |
Insurance contract or identification number | W12267 | Number of Individuals Covered | 362 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $17,644 | Total amount of fees paid to insurance company | USD $6,300 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,553,507 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,644 | Amount paid for insurance broker fees | 6300 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05944742 |
Policy instance | 3 |
Insurance contract or identification number | KM05944742 | Number of Individuals Covered | 538 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $5,343 | Total amount of fees paid to insurance company | USD $3,256 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $208,859 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,343 | Amount paid for insurance broker fees | 52 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5944742 |
Policy instance | 3 |
Insurance contract or identification number | 5944742 | Number of Individuals Covered | 636 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $6,020 | Total amount of fees paid to insurance company | USD $3,473 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $229,732 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,020 | Amount paid for insurance broker fees | 73 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 902247 |
Policy instance | 2 |
Insurance contract or identification number | 902247 | Number of Individuals Covered | 408 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $23,364 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $3,120,904 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 23364 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | Insurance broker organization code? | 3 |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 1754 |
Policy instance | 1 |
Insurance contract or identification number | 1754 | Number of Individuals Covered | 233 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $17,224 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,491,943 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,224 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0ASLP |
Policy instance | 5 |
Insurance contract or identification number | GLUG0ASLP | Number of Individuals Covered | 332 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $19,632 | Total amount of fees paid to insurance company | USD $9,881 | 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 | Welfare Benefit Premiums Paid to Carrier | USD $255,589 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $19,632 | Amount paid for insurance broker fees | 9881 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30039791 |
Policy instance | 4 |
Insurance contract or identification number | 30039791 | Number of Individuals Covered | 223 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,897 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $34,348 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,897 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 902247 |
Policy instance | 2 |
Insurance contract or identification number | 902247 | Number of Individuals Covered | 411 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $25,553 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $3,116,161 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 25553 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5944742 |
Policy instance | 3 |
Insurance contract or identification number | 5944742 | Number of Individuals Covered | 647 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $5,320 | Total amount of fees paid to insurance company | USD $4,739 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $228,556 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,320 | Amount paid for insurance broker fees | 95 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0ASLP |
Policy instance | 5 |
Insurance contract or identification number | GLUG0ASLP | Number of Individuals Covered | 326 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $21,762 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $282,303 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $21,762 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 1754 |
Policy instance | 1 |
Insurance contract or identification number | 1754 | Number of Individuals Covered | 258 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $20,744 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,462,960 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,744 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30039791 |
Policy instance | 4 |
Insurance contract or identification number | 30039791 | Number of Individuals Covered | 211 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $1,546 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $34,215 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,546 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 1754 |
Policy instance | 1 |
Insurance contract or identification number | 1754 | Number of Individuals Covered | 266 | Insurance policy start date | 2016-06-01 | Insurance policy end date | 2017-05-31 | Total amount of commissions paid to insurance broker | USD $19,530 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,458,672 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $19,530 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0ASLP |
Policy instance | 10 |
Insurance contract or identification number | GLUG0ASLP | Number of Individuals Covered | 302 | Insurance policy start date | 2016-06-01 | Insurance policy end date | 2017-05-31 | Total amount of commissions paid to insurance broker | USD $22,148 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $282,040 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $22,148 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
Policy contract number | 686758 |
Policy instance | 5 |
Insurance contract or identification number | 686758 | Number of Individuals Covered | 261 | Insurance policy start date | 2016-06-01 | Insurance policy end date | 2017-05-31 | Total amount of commissions paid to insurance broker | USD $5,653 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $226,495 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,653 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05944742 |
Policy instance | 6 |
Insurance contract or identification number | KM05944742 | Number of Individuals Covered | 559 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $3,520 | Total amount of fees paid to insurance company | USD $2,174 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $123,003 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,520 | Amount paid for insurance broker fees | 57 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 1754 |
Policy instance | 2 |
Insurance contract or identification number | 1754 | Number of Individuals Covered | 264 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $9,630 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $852,569 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,630 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 902247 |
Policy instance | 3 |
Insurance contract or identification number | 902247 | Number of Individuals Covered | 349 | Insurance policy start date | 2016-06-01 | Insurance policy end date | 2017-05-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $24,137 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,342,671 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 24137 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT BONUS | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 902247 |
Policy instance | 4 |
Insurance contract or identification number | 902247 | Number of Individuals Covered | 161 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $10,098 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,425,911 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 10098 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30039791 |
Policy instance | 8 |
Insurance contract or identification number | 30039791 | Number of Individuals Covered | 172 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $1,020 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $17,596 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,020 | Amount paid for insurance broker fees | 0 | Insurance broker name | LOCKTON COMPANIES, LLC |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0ASLP |
Policy instance | 9 |
Insurance contract or identification number | GLUG0ASLP | Number of Individuals Covered | 316 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $17,277 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $167,547 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,277 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30039791 |
Policy instance | 7 |
Insurance contract or identification number | 30039791 | Number of Individuals Covered | 153 | Insurance policy start date | 2016-05-01 | Insurance policy end date | 2017-04-30 | Total amount of commissions paid to insurance broker | USD $1,229 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $24,094 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,229 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 1754 |
Policy instance | 1 |
Insurance contract or identification number | 1754 | Number of Individuals Covered | 317 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $20,652 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,455,857 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,652 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0ASLP |
Policy instance | 7 |
Insurance contract or identification number | GLTD0ASLP | Number of Individuals Covered | 278 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $4,572 | Total amount of fees paid to insurance company | USD $1,162 | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $57,219 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,572 | Amount paid for insurance broker fees | 1162 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
Policy contract number | 686758 |
Policy instance | 2 |
Insurance contract or identification number | 686758 | Number of Individuals Covered | 242 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $3,337 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $109,284 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,337 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 5-07612 |
Policy instance | 3 |
Insurance contract or identification number | 5-07612 | Number of Individuals Covered | 15 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $1,057 | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,950 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $461 | Insurance broker organization code? | 3 | Insurance broker name | SECURA CONSULTANTS |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30039791 |
Policy instance | 4 |
Insurance contract or identification number | 30039791 | Number of Individuals Covered | 97 | Insurance policy start date | 2014-05-01 | Insurance policy end date | 2015-04-30 | Total amount of commissions paid to insurance broker | USD $986 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $16,634 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $986 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0ASLP |
Policy instance | 5 |
Insurance contract or identification number | GVTL0ASLP | Number of Individuals Covered | 88 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $9,383 | Total amount of fees paid to insurance company | USD $2,417 | Other welfare benefits provided | VOLUNTARY: LIFE AND AD&D | Welfare Benefit Premiums Paid to Carrier | USD $102,069 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,383 | Amount paid for insurance broker fees | 2417 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0ASLP |
Policy instance | 6 |
Insurance contract or identification number | GLUG0ASLP | Number of Individuals Covered | 279 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $3,784 | Total amount of fees paid to insurance company | USD $985 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $45,687 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,784 | Amount paid for insurance broker fees | 985 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG 0ASLP |
Policy instance | 8 |
Insurance contract or identification number | GUG 0ASLP | Number of Individuals Covered | 279 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $4,627 | Total amount of fees paid to insurance company | USD $1,594 | Temporary Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $75,089 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,627 | Amount paid for insurance broker fees | 1594 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 902247 |
Policy instance | 9 |
Insurance contract or identification number | 902247 | Number of Individuals Covered | 261 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of fees paid to insurance company | USD $16,016 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,703,106 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 16016 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 ) |
Policy contract number | 344 |
Policy instance | 1 |
Insurance contract or identification number | 344 | Number of Individuals Covered | 63 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $15,149 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $362,064 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,031 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 1754 |
Policy instance | 2 |
Insurance contract or identification number | 1754 | Number of Individuals Covered | 470 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $25,515 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,563,595 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,822 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
Policy contract number | 686758 |
Policy instance | 3 |
Insurance contract or identification number | 686758 | Number of Individuals Covered | 248 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $5,782 | Total amount of fees paid to insurance company | USD $3,217 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $231,930 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $415 | Amount paid for insurance broker fees | 3217 | Additional information about fees paid to insurance broker | VOLUME INCENTIVES | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 72284 |
Policy instance | 4 |
Insurance contract or identification number | 72284 | Number of Individuals Covered | 25 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $4,787 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $102,179 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,022 | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE SOLUTIONS, INC. |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 1035616 |
Policy instance | 5 |
Insurance contract or identification number | 1035616 | Number of Individuals Covered | 280 | Insurance policy start date | 2013-07-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $7,028 | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $99,216 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,922 | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE SOLUTIONS, INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 54682 ) |
Policy contract number | 30039791 |
Policy instance | 7 |
Insurance contract or identification number | 30039791 | Number of Individuals Covered | 79 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2014-04-30 | Total amount of commissions paid to insurance broker | USD $852 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $12,866 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $660 | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 ) |
Policy contract number | 130808 |
Policy instance | 6 |
Insurance contract or identification number | 130808 | Number of Individuals Covered | 209 | Insurance policy start date | 2014-03-01 | Insurance policy end date | 2014-05-31 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $25,056 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 1754 |
Policy instance | 2 |
Insurance contract or identification number | 1754 | Number of Individuals Covered | 435 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $24,645 | 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 $2,021,608 | Commission paid to Insurance Broker | USD $24,645 | Insurance broker organization code? | 3 | Insurance broker name | KEVIN CLOUGHERTY |
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UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 ) |
Policy contract number | 130808 |
Policy instance | 3 |
Insurance contract or identification number | 130808 | Number of Individuals Covered | 208 | Insurance policy start date | 2013-03-01 | Insurance policy end date | 2014-02-28 | Total amount of commissions paid to insurance broker | USD $0 | 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 | ADD | 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 $148,935 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 72284 |
Policy instance | 1 |
Insurance contract or identification number | 72284 | Number of Individuals Covered | 24 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $4,538 | 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 $95,595 | Commission paid to Insurance Broker | USD $4,538 | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE SOLUTIONS, INC |
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CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 ) |
Policy contract number | 344 |
Policy instance | 4 |
Insurance contract or identification number | 344 | Number of Individuals Covered | 34 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $10,032 | 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 $225,791 | Commission paid to Insurance Broker | USD $10,032 | Insurance broker organization code? | 3 | Insurance broker name | MORTENSON MATZELLE & MELDRUM INC |
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HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
Policy contract number | 686758 |
Policy instance | 5 |
Insurance contract or identification number | 686758 | Number of Individuals Covered | 226 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $6,048 | Total amount of fees paid to insurance company | USD $4,207 | 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 $205,433 | Commission paid to Insurance Broker | USD $6,048 | Amount paid for insurance broker fees | 4207 | Additional information about fees paid to insurance broker | VOLUME INCENTIVES | Insurance broker organization code? | 3 | Insurance broker name | MORTENSON MATZELLE AND MELDRUM INC |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 1035616 |
Policy instance | 6 |
Insurance contract or identification number | 1035616 | Number of Individuals Covered | 263 | Insurance policy start date | 2013-03-01 | Insurance policy end date | 2013-06-30 | Total amount of commissions paid to insurance broker | USD $3,370 | 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 | 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 $27,173 | Commission paid to Insurance Broker | USD $3,370 | Insurance broker organization code? | 3 | Insurance broker name | M3 INS SOLUTIONS INC |
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CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 ) |
Policy contract number | 1799 |
Policy instance | 4 |
Insurance contract or identification number | 1799 | Number of Individuals Covered | 30 | Insurance policy start date | 2011-06-01 | Insurance policy end date | 2012-05-31 | Total amount of commissions paid to insurance broker | USD $8,413 | 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 $186,953 | Commission paid to Insurance Broker | USD $8,413 | Insurance broker organization code? | 3 | Insurance broker name | MORTENSON MATZELLE & MELDRUM INC |
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HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
Policy contract number | 686758 |
Policy instance | 6 |
Insurance contract or identification number | 686758 | Number of Individuals Covered | 218 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $12,665 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $181,938 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | 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 | 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 | 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 | Commission paid to Insurance Broker | USD $12,665 | Insurance broker organization code? | 3 | Insurance broker name | MORTENSON MATZELLE AND MELDRUM INC |
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CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 ) |
Policy contract number | 001799 |
Policy instance | 4 |
Insurance contract or identification number | 001799 | Number of Individuals Covered | 30 | Insurance policy start date | 2011-06-01 | Insurance policy end date | 2012-05-31 | Total amount of commissions paid to insurance broker | USD $8,413 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $186,953 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 ) |
Policy contract number | 130808 |
Policy instance | 3 |
Insurance contract or identification number | 130808 | Number of Individuals Covered | 192 | Insurance policy start date | 2012-03-01 | Insurance policy end date | 2013-02-28 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $128,953 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | 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 | 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 | 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 |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 17540-17545 |
Policy instance | 2 |
Insurance contract or identification number | 17540-17545 | Number of Individuals Covered | 420 | Insurance policy start date | 2011-06-01 | Insurance policy end date | 2012-05-31 | Total amount of commissions paid to insurance broker | USD $23,337 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,801,437 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | 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 | 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 | 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 | Commission paid to Insurance Broker | USD $23,337 | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 72284 |
Policy instance | 1 |
Insurance contract or identification number | 72284 | Number of Individuals Covered | 21 | Insurance policy start date | 2011-06-01 | Insurance policy end date | 2012-05-31 | Total amount of commissions paid to insurance broker | USD $5,321 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $79,142 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | 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 | 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 | 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 | Commission paid to Insurance Broker | USD $5,321 | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE SOLUTIONS, INC |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | H36903 |
Policy instance | 7 |
Insurance contract or identification number | H36903 | Number of Individuals Covered | 256 | Insurance policy start date | 2012-07-01 | Insurance policy end date | 2013-02-28 | Total amount of commissions paid to insurance broker | USD $4,895 | 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 | 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 $48,526 | Commission paid to Insurance Broker | USD $4,895 | Insurance broker organization code? | 3 | Insurance broker name | M3 INS SOLUTIONS INC |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | H36903 |
Policy instance | 5 |
Insurance contract or identification number | H36903 | Number of Individuals Covered | 240 | Insurance policy start date | 2011-07-01 | Insurance policy end date | 2012-06-30 | Total amount of commissions paid to insurance broker | USD $6,502 | Total amount of fees paid to insurance company | USD $1,340 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $82,973 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | 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 | 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 | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life 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 | Commission paid to Insurance Broker | USD $6,502 | Amount paid for insurance broker fees | 1340 | Additional information about fees paid to insurance broker | SERVICE FEE, BONUS | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE SOLUTIONS, INC |
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HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
Policy contract number | 686758 |
Policy instance | 6 |
Insurance contract or identification number | 686758 | Number of Individuals Covered | 198 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $11,543 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $175,377 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | H36903 |
Policy instance | 5 |
Insurance contract or identification number | H36903 | Number of Individuals Covered | 223 | Insurance policy start date | 2010-07-01 | Insurance policy end date | 2011-06-30 | Total amount of commissions paid to insurance broker | USD $7,183 | Total amount of fees paid to insurance company | USD $23,747 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $548,873 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 ) |
Policy contract number | 001799 |
Policy instance | 4 |
Insurance contract or identification number | 001799 | Number of Individuals Covered | 32 | Insurance policy start date | 2010-06-01 | Insurance policy end date | 2011-05-31 | Total amount of commissions paid to insurance broker | USD $8,077 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $179,483 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 ) |
Policy contract number | 130808 |
Policy instance | 3 |
Insurance contract or identification number | 130808 | Number of Individuals Covered | 164 | Insurance policy start date | 2011-03-01 | Insurance policy end date | 2012-02-28 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $113,200 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 17540-17545 |
Policy instance | 2 |
Insurance contract or identification number | 17540-17545 | Number of Individuals Covered | 325 | Insurance policy start date | 2010-06-01 | Insurance policy end date | 2011-05-31 | Total amount of commissions paid to insurance broker | USD $21,091 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,175,935 | 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: 0000 ) |
Policy contract number | 72284 |
Policy instance | 1 |
Insurance contract or identification number | 72284 | Number of Individuals Covered | 25 | Insurance policy start date | 2010-06-01 | Insurance policy end date | 2011-05-31 | Total amount of commissions paid to insurance broker | USD $4,719 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $75,580 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
Policy contract number | 686758 |
Policy instance | 6 |
Insurance contract or identification number | 686758 | Number of Individuals Covered | 185 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $10,844 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $194,150 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,844 | Insurance broker name | MORTENSON MATZELLE AND MELDRUM INC |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | H36903 |
Policy instance | 5 |
Insurance contract or identification number | H36903 | Number of Individuals Covered | 228 | Insurance policy start date | 2009-07-01 | Insurance policy end date | 2010-06-30 | Total amount of commissions paid to insurance broker | USD $7,168 | Total amount of fees paid to insurance company | USD $26,123 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $525,065 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,168 | Amount paid for insurance broker fees | 26123 | Additional information about fees paid to insurance broker | SERVICE FEE, BONUS | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE SOLUTIONS, INC. |
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CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 ) |
Policy contract number | 001799 |
Policy instance | 4 |
Insurance contract or identification number | 001799 | Number of Individuals Covered | 31 | Insurance policy start date | 2009-06-01 | Insurance policy end date | 2010-05-31 | Total amount of commissions paid to insurance broker | USD $6,425 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $142,767 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,425 | Insurance broker name | MORTENSON MATZELLE & MELDRUM INC |
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UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 ) |
Policy contract number | 130808 |
Policy instance | 3 |
Insurance contract or identification number | 130808 | Number of Individuals Covered | 163 | Insurance policy start date | 2010-03-01 | Insurance policy end date | 2011-02-28 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $115,751 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
Policy contract number | 17540-17545 |
Policy instance | 2 |
Insurance contract or identification number | 17540-17545 | Number of Individuals Covered | 332 | Insurance policy start date | 2009-06-01 | Insurance policy end date | 2010-05-31 | Total amount of commissions paid to insurance broker | USD $23,287 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,413,740 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $23,287 | Insurance broker name | M3 INSURANCE SOLUTIONS, INC. |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 72284 |
Policy instance | 1 |
Insurance contract or identification number | 72284 | Number of Individuals Covered | 24 | Insurance policy start date | 2009-06-01 | Insurance policy end date | 2010-05-31 | Total amount of commissions paid to insurance broker | USD $4,830 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $81,694 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,830 | Insurance broker name | JAMES KROGSTAD |
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