401k Plan data: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN plan

ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN
Plan identification number	501

ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

ALTO PHARMACY, LLC has sponsored the creation of one or more 401k plans.

Company Name: ALTO PHARMACY, LLC

Employer identification number (EIN): 474390076

NAIC Classification: 446110
NAIC Description: Pharmacies and Drug Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 LISA BLAGO 2023-06-22
501 2021-01-01 ROSVITA LISA BLAGOJEVIC 2022-07-10
501 2020-01-01 NEIL FRYE 2021-07-15
501 2019-01-01 NEIL FRY 2020-07-14
501 2018-02-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	LISA BLAGO	2023-06-22
501	2021-01-01	ROSVITA LISA BLAGOJEVIC	2022-07-10
501	2020-01-01	NEIL FRYE	2021-07-15
501	2019-01-01	NEIL FRY	2020-07-14
501	2018-02-01

Plan Statistics for ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2022: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 965
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 762
Number of retired or separated participants receiving benefits 2022-01-01 17
Total of all active and inactive participants 2022-01-01 779
2021: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 639
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 955
Number of retired or separated participants receiving benefits 2021-01-01 10
Total of all active and inactive participants 2021-01-01 965
2020: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 367
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 635
Number of retired or separated participants receiving benefits 2020-01-01 14
Total of all active and inactive participants 2020-01-01 649
2019: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 159
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 341
Number of retired or separated participants receiving benefits 2019-01-01 2
Total of all active and inactive participants 2019-01-01 343
2018: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-02-01 112
Total number of active participants reported on line 7a of the Form 5500 2018-02-01 155
Number of retired or separated participants receiving benefits 2018-02-01 0
Number of other retired or separated participants entitled to future benefits 2018-02-01 0
Total of all active and inactive participants 2018-02-01 155
Number of employers contributing to the scheme 2018-02-01 0

Measure	Date	Value
2022: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	965
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	762
Number of retired or separated participants receiving benefits	2022-01-01	17
Total of all active and inactive participants	2022-01-01	779
2021: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	639
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	955
Number of retired or separated participants receiving benefits	2021-01-01	10
Total of all active and inactive participants	2021-01-01	965
2020: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	367
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	635
Number of retired or separated participants receiving benefits	2020-01-01	14
Total of all active and inactive participants	2020-01-01	649
2019: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	159
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	341
Number of retired or separated participants receiving benefits	2019-01-01	2
Total of all active and inactive participants	2019-01-01	343
2018: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-02-01	112
Total number of active participants reported on line 7a of the Form 5500	2018-02-01	155
Number of retired or separated participants receiving benefits	2018-02-01	0
Number of other retired or separated participants entitled to future benefits	2018-02-01	0
Total of all active and inactive participants	2018-02-01	155
Number of employers contributing to the scheme	2018-02-01	0

Form 5500 Responses for ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN

2022: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: ALTO PHARMACY, LLC HEALTH AND WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-02-01	Type of plan entity	Single employer plan
2018-02-01	First time form 5500 has been submitted	Yes
2018-02-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2018-02-01	Plan funding arrangement – Insurance	Yes
2018-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-02-01	Plan benefit arrangement – Insurance	Yes
2018-02-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX969959

Policy instance

Insurance contract or identification number	FLX969959
Number of Individuals Covered	270
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,324
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $63,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,324
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK606508

Policy instance

Insurance contract or identification number	SOK606508
Number of Individuals Covered	762
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,967
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,667
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,967
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM608818

Policy instance

Insurance contract or identification number	SGM608818
Number of Individuals Covered	762
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,154
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $61,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,154
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605871

Policy instance

Insurance contract or identification number	605871
Number of Individuals Covered	84
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $34,139
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $618,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,139
Insurance broker organization code?	3

MODERN HEALTH ARIZONA P.L.L.C (National Association of Insurance Commissioners NAIC id number: 62139 )

Policy contract number

Policy instance

Number of Individuals Covered	767
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
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EAP
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 $103,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )

Policy contract number

47065

Policy instance

Insurance contract or identification number	47065
Number of Individuals Covered	44
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $14,632
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $316,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,632
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD609429

Policy instance

Insurance contract or identification number	SGD609429
Number of Individuals Covered	762
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,569
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	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 $95,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,569
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

233866

Policy instance

Insurance contract or identification number	233866
Number of Individuals Covered	17
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,987
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $120,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,987
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK971404

Policy instance

Insurance contract or identification number	OK971404
Number of Individuals Covered	270
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,241
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,241
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK606508

Policy instance

Insurance contract or identification number	SOK606508
Number of Individuals Covered	955
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,610
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,610
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM608818

Policy instance

Insurance contract or identification number	SGM608818
Number of Individuals Covered	955
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,202
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $52,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,202
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

20636

Policy instance

Insurance contract or identification number	20636
Number of Individuals Covered	66
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $28,349
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $166,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,343
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605871

Policy instance

Insurance contract or identification number	605871
Number of Individuals Covered	99
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $26,603
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $648,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,603
Insurance broker organization code?	3

MODERN LIFE INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Number of Individuals Covered	879
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
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EAP
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 $138,100
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )

Policy contract number

47065

Policy instance

Insurance contract or identification number	47065
Number of Individuals Covered	53
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $14,778
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $423,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,778
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD609429

Policy instance

Insurance contract or identification number	SGD609429
Number of Individuals Covered	955
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $12,239
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	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 $122,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,239
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

233866

Policy instance

Insurance contract or identification number	233866
Number of Individuals Covered	16
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,364
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $78,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,364
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00531395

Policy instance

Insurance contract or identification number	00531395
Number of Individuals Covered	571
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,404
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
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 $74,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,404
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD610278

Policy instance

Insurance contract or identification number	SGD610278
Number of Individuals Covered	361
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,077
Total amount of fees paid to insurance company	USD $1,168
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	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 $41,545
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,077
Amount paid for insurance broker fees	1168
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

233866

Policy instance

Insurance contract or identification number	233866
Number of Individuals Covered	14
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,900
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $61,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,900
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD609429

Policy instance

Insurance contract or identification number	SGD609429
Number of Individuals Covered	635
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,730
Total amount of fees paid to insurance company	USD $631
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	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 $17,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,730
Amount paid for insurance broker fees	631
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK606508

Policy instance

Insurance contract or identification number	SOK606508
Number of Individuals Covered	635
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $349
Total amount of fees paid to insurance company	USD $130
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $349
Amount paid for insurance broker fees	130
Additional information about fees paid to insurance broker	OVVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM608818

Policy instance

Insurance contract or identification number	SGM608818
Number of Individuals Covered	635
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,091
Total amount of fees paid to insurance company	USD $378
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,091
Amount paid for insurance broker fees	378
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

Policy instance

Number of Individuals Covered	28
Insurance policy start date	2020-07-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,176
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,408
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605871

Policy instance

Insurance contract or identification number	605871
Number of Individuals Covered	93
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $26,422
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $523,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,422
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

0621855

Policy instance

Insurance contract or identification number	0621855
Number of Individuals Covered	556
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,211
Total amount of fees paid to insurance company	USD $1,169
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,211
Amount paid for insurance broker fees	1169
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )

Policy contract number

47065

Policy instance

Insurance contract or identification number	47065
Number of Individuals Covered	71
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,196
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $323,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,196
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK606508

Policy instance

Insurance contract or identification number	SOK606508
Number of Individuals Covered	367
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $422
Total amount of fees paid to insurance company	USD $56
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $422
Amount paid for insurance broker fees	56
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

0621855

Policy instance

Insurance contract or identification number	0621855
Number of Individuals Covered	277
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,451
Total amount of fees paid to insurance company	USD $630
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,910
Insurance broker organization code?	3
Amount paid for insurance broker fees	630
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00531395

Policy instance

Insurance contract or identification number	00531395
Number of Individuals Covered	310
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,582
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
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 $36,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,582
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

233866

Policy instance

Insurance contract or identification number	233866
Number of Individuals Covered	9
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,512
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,262
Commission paid to Insurance Broker	USD $1,512
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM608818

Policy instance

Insurance contract or identification number	SGM608818
Number of Individuals Covered	367
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,335
Total amount of fees paid to insurance company	USD $177
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,335
Amount paid for insurance broker fees	177
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD609429

Policy instance

Insurance contract or identification number	SGD609429
Number of Individuals Covered	367
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,004
Total amount of fees paid to insurance company	USD $283
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	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 $20,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,004
Amount paid for insurance broker fees	283
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605871

Policy instance

Insurance contract or identification number	605871
Number of Individuals Covered	53
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $13,952
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $258,422
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,952
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD610278

Policy instance

Insurance contract or identification number	SGD610278
Number of Individuals Covered	193
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,293
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	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 $25,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,293
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605871

Policy instance

Insurance contract or identification number	605871
Number of Individuals Covered	48
Insurance policy start date	2018-02-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $10,257
Total amount of fees paid to insurance company	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $227,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,738
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM608818

Policy instance

Insurance contract or identification number	SGM608818
Number of Individuals Covered	155
Insurance policy start date	2018-02-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,869
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $18,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,002
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

531395

Policy instance

Insurance contract or identification number	531395
Number of Individuals Covered	144
Insurance policy start date	2018-02-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,775
Total amount of fees paid to insurance company	USD $677
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,005
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

621855

Policy instance

Insurance contract or identification number	621855
Number of Individuals Covered	144
Insurance policy start date	2018-02-01
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 $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	ALTO PHARMACY, LLC
Employer identification number (EIN):	474390076
NAIC Classification:	446110
NAIC Description:	Pharmacies and Drug Stores