401k Plan data: TIVO CORPORATION HEALTH PLAN plan

TIVO CORPORATION HEALTH PLAN 401k Plan overview

Plan Name	TIVO CORPORATION HEALTH PLAN
Plan identification number	511

TIVO CORPORATION HEALTH 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) Prepaid legal Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

TIVO CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: TIVO CORPORATION

Employer identification number (EIN): 611793262

NAIC Classification: 511210
NAIC Description: Software Publishers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TIVO CORPORATION HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
511 2020-01-01 JENNI NGO 2021-07-21
511 2019-01-01 JENNI NGO 2020-06-03
511 2018-01-01
511 2017-01-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
511	2020-01-01	JENNI NGO	2021-07-21
511	2019-01-01	JENNI NGO	2020-06-03
511	2018-01-01
511	2017-01-01

Plan Statistics for TIVO CORPORATION HEALTH PLAN

401k plan membership statisitcs for TIVO CORPORATION HEALTH PLAN

Measure Date Value
2020: TIVO CORPORATION HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 977
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 0
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 0
Number of employers contributing to the scheme 2020-01-01 0
2019: TIVO CORPORATION HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,088
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 817
Number of retired or separated participants receiving benefits 2019-01-01 49
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 866
2018: TIVO CORPORATION HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 1,192
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 1,040
Number of retired or separated participants receiving benefits 2018-01-01 48
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 1,088
2017: TIVO CORPORATION HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 1,285
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 1,144
Number of retired or separated participants receiving benefits 2017-01-01 48
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 1,192

Measure	Date	Value
2020: TIVO CORPORATION HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	977
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	0
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	0
Number of employers contributing to the scheme	2020-01-01	0
2019: TIVO CORPORATION HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,088
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	817
Number of retired or separated participants receiving benefits	2019-01-01	49
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	866
2018: TIVO CORPORATION HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	1,192
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,040
Number of retired or separated participants receiving benefits	2018-01-01	48
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	1,088
2017: TIVO CORPORATION HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,285
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,144
Number of retired or separated participants receiving benefits	2017-01-01	48
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	1,192

Form 5500 Responses for TIVO CORPORATION HEALTH PLAN

2020: TIVO CORPORATION HEALTH PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	This submission is the final filing	Yes
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: TIVO CORPORATION HEALTH 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: TIVO CORPORATION HEALTH PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: TIVO CORPORATION HEALTH PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

230254

Policy instance

Insurance contract or identification number	230254
Insurance contract or identification number	230254
Number of Individuals Covered	254
Number of Individuals Covered	254
Insurance policy start date	2020-01-01
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $48,498
Total amount of commissions paid to insurance broker	USD $48,498
Total amount of fees paid to insurance company	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $2,046,075
Welfare Benefit Premiums Paid to Carrier	USD $2,046,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

00272486/0001

Policy instance

Insurance contract or identification number	00272486/0001
Insurance contract or identification number	00272486/0001
Number of Individuals Covered	666
Number of Individuals Covered	666
Insurance policy start date	2020-01-01
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $437,137
Welfare Benefit Premiums Paid to Carrier	USD $437,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

00272486/0001

Policy instance

Insurance contract or identification number	00272486/0001
Insurance contract or identification number	00272486/0001
Number of Individuals Covered	666
Number of Individuals Covered	666
Insurance policy start date	2020-01-01
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $437,137
Welfare Benefit Premiums Paid to Carrier	USD $437,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EMPATHIA PACIFIC, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance contract or identification number	00
Insurance contract or identification number	00
Number of Individuals Covered	666
Number of Individuals Covered	666
Insurance policy start date	2020-01-01
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $10,427
Welfare Benefit Premiums Paid to Carrier	USD $10,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677991G

Policy instance

Insurance contract or identification number	677991G
Insurance contract or identification number	677991G
Number of Individuals Covered	664
Number of Individuals Covered	664
Insurance policy start date	2020-01-01
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $21,698
Total amount of commissions paid to insurance broker	USD $21,698
Total amount of fees paid to insurance company	USD $7,841
Total amount of fees paid to insurance company	USD $7,841
Life Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $867,931
Welfare Benefit Premiums Paid to Carrier	USD $867,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677991G

Policy instance

Insurance contract or identification number	677991G
Insurance contract or identification number	677991G
Number of Individuals Covered	664
Number of Individuals Covered	664
Insurance policy start date	2020-01-01
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $21,698
Total amount of commissions paid to insurance broker	USD $21,698
Total amount of fees paid to insurance company	USD $7,841
Total amount of fees paid to insurance company	USD $7,841
Life Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $867,931
Welfare Benefit Premiums Paid to Carrier	USD $867,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

MTA0009153966

Policy instance

Insurance contract or identification number	MTA0009153966
Insurance contract or identification number	MTA0009153966
Number of Individuals Covered	666
Number of Individuals Covered	666
Insurance policy start date	2019-10-16
Insurance policy start date	2019-10-16
Insurance policy end date	2020-09-30
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $6,954
Total amount of commissions paid to insurance broker	USD $6,954
Total amount of fees paid to insurance company	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $34,769
Welfare Benefit Premiums Paid to Carrier	USD $34,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

MTA0009153966

Policy instance

Insurance contract or identification number	MTA0009153966
Insurance contract or identification number	MTA0009153966
Number of Individuals Covered	666
Number of Individuals Covered	666
Insurance policy start date	2019-10-16
Insurance policy start date	2019-10-16
Insurance policy end date	2020-09-30
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $6,954
Total amount of commissions paid to insurance broker	USD $6,954
Total amount of fees paid to insurance company	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $34,769
Welfare Benefit Premiums Paid to Carrier	USD $34,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1500946

Policy instance

Insurance contract or identification number	1500946
Number of Individuals Covered	148
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,523
Total amount of commissions paid to insurance broker	USD $3,523
Total amount of fees paid to insurance company	USD $575
Total amount of fees paid to insurance company	USD $575
Other welfare benefits provided	LEGAL
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $35,245
Welfare Benefit Premiums Paid to Carrier	USD $35,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	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 $2,734
Amount paid for insurance broker fees	575
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

MTA0009153966

Policy instance

Insurance contract or identification number	MTA0009153966
Insurance contract or identification number	MTA0009153966
Number of Individuals Covered	666
Number of Individuals Covered	666
Insurance policy start date	2020-10-01
Insurance policy start date	2020-10-01
Insurance policy end date	2020-10-15
Insurance policy end date	2020-10-15
Total amount of commissions paid to insurance broker	USD $0
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $0
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

MTA0009153966

Policy instance

Insurance contract or identification number	MTA0009153966
Insurance contract or identification number	MTA0009153966
Number of Individuals Covered	666
Number of Individuals Covered	666
Insurance policy start date	2020-10-01
Insurance policy start date	2020-10-01
Insurance policy end date	2020-10-15
Insurance policy end date	2020-10-15
Total amount of commissions paid to insurance broker	USD $0
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $0
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

230254

Policy instance

Insurance contract or identification number	230254
Insurance contract or identification number	230254
Number of Individuals Covered	254
Number of Individuals Covered	254
Insurance policy start date	2020-01-01
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $48,498
Total amount of commissions paid to insurance broker	USD $48,498
Total amount of fees paid to insurance company	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $2,046,075
Welfare Benefit Premiums Paid to Carrier	USD $2,046,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1500946

Policy instance

Insurance contract or identification number	1500946
Number of Individuals Covered	203
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,629
Total amount of fees paid to insurance company	USD $651
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	LEGAL
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 $46,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,629
Amount paid for insurance broker fees	42
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

MTA 0009153966

Policy instance

Insurance contract or identification number	MTA 0009153966
Number of Individuals Covered	835
Insurance policy start date	2018-10-16
Insurance policy end date	2019-10-15
Total amount of commissions paid to insurance broker	USD $6,954
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	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,954
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

35084

Policy instance

Insurance contract or identification number	35084
Number of Individuals Covered	312
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $52,088
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 $2,016,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,088
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

230254

Policy instance

Insurance contract or identification number	230254
Number of Individuals Covered	26
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,188
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 $165,473
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,188
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677991G

Policy instance

Insurance contract or identification number	677991G
Number of Individuals Covered	835
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $27,877
Total amount of fees paid to insurance company	USD $16,692
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,115,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,877
Insurance broker organization code?	3
Amount paid for insurance broker fees	16692
Additional information about fees paid to insurance broker	BONUS

EMPATHIA PACIFIC, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

00000

Policy instance

Insurance contract or identification number	00000
Number of Individuals Covered	840
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00272486/0001

Policy instance

Insurance contract or identification number	00272486/0001
Number of Individuals Covered	81
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $22,703
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 $415,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,703
Insurance broker organization code?	3

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00272486/0001

Policy instance

Insurance contract or identification number	00272486/0001
Number of Individuals Covered	71
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $15,349
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 $317,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,349
Insurance broker organization code?	3

EMPATHIA PACIFIC, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

00000

Policy instance

Insurance contract or identification number	00000
Number of Individuals Covered	1047
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
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	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677991G

Policy instance

Insurance contract or identification number	677991G
Number of Individuals Covered	1040
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $26,446
Total amount of fees paid to insurance company	USD $16,076
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,057,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,446
Insurance broker organization code?	3
Amount paid for insurance broker fees	16076
Additional information about fees paid to insurance broker	BONUS

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

230254

Policy instance

Insurance contract or identification number	230254
Number of Individuals Covered	21
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,452
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 $112,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,452
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

35084

Policy instance

Insurance contract or identification number	35084
Number of Individuals Covered	346
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $52,148
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 $2,178,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,148
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

MTA 0009153966

Policy instance

Insurance contract or identification number	MTA 0009153966
Number of Individuals Covered	1040
Insurance policy start date	2017-10-16
Insurance policy end date	2018-10-15
Total amount of commissions paid to insurance broker	USD $6,954
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	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,954
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP 0009152619

Policy instance

Insurance contract or identification number	GTP 0009152619
Number of Individuals Covered	1144
Insurance policy start date	2017-01-01
Insurance policy end date	2017-10-16
Total amount of commissions paid to insurance broker	USD $2,013
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	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,013
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH AND BENEFITS LLC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

35084

Policy instance

Insurance contract or identification number	35084
Number of Individuals Covered	387
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $47,551
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 $2,148,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,551
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH AND BENEFITS LLC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

230254

Policy instance

Insurance contract or identification number	230254
Number of Individuals Covered	19
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,228
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 $93,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,228
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH AND BENEFITS LLC

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677991G

Policy instance

Insurance contract or identification number	677991G
Number of Individuals Covered	1144
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $27,224
Total amount of fees paid to insurance company	USD $14,967
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,088,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,224
Insurance broker organization code?	3
Amount paid for insurance broker fees	14967
Additional information about fees paid to insurance broker	FEES
Insurance broker name	MERCER HUMAN RESOURCE

EMPATHIA PACIFIC, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

00000

Policy instance

Insurance contract or identification number	00000
Number of Individuals Covered	1147
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
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	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00272486 0001

Policy instance

Insurance contract or identification number	00272486 0001
Number of Individuals Covered	65
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $15,460
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 $334,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,460
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH AND BENEFITS LLC

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Company Name:	TIVO CORPORATION
Employer identification number (EIN):	611793262
NAIC Classification:	511210
NAIC Description:	Software Publishers