THE WOODLANDS STORE, INC. has sponsored the creation of one or more 401k plans.
Additional information about THE WOODLANDS STORE, INC.
Submission information for form 5500 for 401k plan WOODLANDS MARKET EMPLOYEE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2021: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 170 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 156 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 156 |
| Number of employers contributing to the scheme | 2021-10-01 | 0 |
| 2020: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 174 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 172 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 172 |
| Number of employers contributing to the scheme | 2020-10-01 | 0 |
| 2019: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 164 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 174 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 174 |
| Number of employers contributing to the scheme | 2019-10-01 | 0 |
| 2018: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 172 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 164 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 164 |
| Number of employers contributing to the scheme | 2018-10-01 | 0 |
| 2017: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 148 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 172 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 172 |
| Number of employers contributing to the scheme | 2017-10-01 | 0 |
| 2016: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 136 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 148 |
| Number of retired or separated participants receiving benefits | 2016-10-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
| Total of all active and inactive participants | 2016-10-01 | 149 |
| Number of employers contributing to the scheme | 2016-10-01 | 0 |
| 2015: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 134 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
| Total of all active and inactive participants | 2015-10-01 | 136 |
| Number of employers contributing to the scheme | 2015-10-01 | 0 |
| 2014: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 138 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 115 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-10-01 | 10 |
| Total of all active and inactive participants | 2014-10-01 | 125 |
| Number of employers contributing to the scheme | 2014-10-01 | 0 |
| 2013: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 128 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 112 |
| Number of retired or separated participants receiving benefits | 2013-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-10-01 | 0 |
| Total of all active and inactive participants | 2013-10-01 | 112 |
| Number of employers contributing to the scheme | 2013-10-01 | 0 |
| 2012: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-10-01 | 124 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 136 |
| Number of retired or separated participants receiving benefits | 2012-10-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2012-10-01 | 0 |
| Total of all active and inactive participants | 2012-10-01 | 138 |
| Number of employers contributing to the scheme | 2012-10-01 | 0 |
| 2011: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 119 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 123 |
| Number of retired or separated participants receiving benefits | 2011-10-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2011-10-01 | 0 |
| Total of all active and inactive participants | 2011-10-01 | 124 |
| Number of employers contributing to the scheme | 2011-10-01 | 0 |
| 2010: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-10-01 | 138 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-10-01 | 132 |
| Total of all active and inactive participants | 2010-10-01 | 132 |
| 2009: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-10-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-10-01 | 138 |
| Number of retired or separated participants receiving benefits | 2009-10-01 | 0 |
| Total of all active and inactive participants | 2009-10-01 | 138 |
| 2021: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Submission has been amended | No |
| 2016-10-01 | This submission is the final filing | No |
| 2016-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-10-01 | Plan is a collectively bargained plan | No |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Submission has been amended | No |
| 2015-10-01 | This submission is the final filing | No |
| 2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-10-01 | Plan is a collectively bargained plan | No |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Submission has been amended | No |
| 2014-10-01 | This submission is the final filing | No |
| 2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-10-01 | Plan is a collectively bargained plan | No |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | Submission has been amended | No |
| 2013-10-01 | This submission is the final filing | No |
| 2013-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-10-01 | Plan is a collectively bargained plan | No |
| 2013-10-01 | Plan funding arrangement – Insurance | Yes |
| 2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-10-01 | Type of plan entity | Single employer plan |
| 2012-10-01 | Submission has been amended | No |
| 2012-10-01 | This submission is the final filing | No |
| 2012-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-10-01 | Plan is a collectively bargained plan | No |
| 2012-10-01 | Plan funding arrangement – Insurance | Yes |
| 2012-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Submission has been amended | No |
| 2011-10-01 | This submission is the final filing | No |
| 2011-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-10-01 | Plan is a collectively bargained plan | No |
| 2011-10-01 | Plan funding arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-10-01 | Type of plan entity | Single employer plan |
| 2010-10-01 | Plan funding arrangement – Insurance | Yes |
| 2010-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: WOODLANDS MARKET EMPLOYEE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-10-01 | Type of plan entity | Single employer plan |
| 2009-10-01 | This submission is the final filing | No |
| 2009-10-01 | Plan funding arrangement – Insurance | Yes |
| 2009-10-01 | Plan benefit arrangement – Insurance | Yes |
| MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 2683 |
| Policy instance | 5 |
| Insurance contract or identification number | 2683 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $3,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00025693 |
| Policy instance | 4 |
| Insurance contract or identification number | ER00025693 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $3,566 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $32,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,451 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603430 |
| Policy instance | 3 |
| Insurance contract or identification number | 603430 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $393 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $786,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 393 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051092 |
| Policy instance | 2 |
| Insurance contract or identification number | W0051092 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $805,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12222727 |
| Policy instance | 1 |
| Insurance contract or identification number | 12222727 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,070 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,578 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,070 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0121A |
| Policy instance | 6 |
| Insurance contract or identification number | GLUG0121A | | Number of Individuals Covered | 151 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $3,229 | | 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 $21,526 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,229 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12222727 |
| Policy instance | 1 |
| Insurance contract or identification number | 12222727 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $1,173 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,234 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,173 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051092 |
| Policy instance | 2 |
| Insurance contract or identification number | W0051092 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $771,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603430 |
| Policy instance | 3 |
| Insurance contract or identification number | 603430 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $816,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00025693 |
| Policy instance | 4 |
| Insurance contract or identification number | ER00025693 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $4,744 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $37,747 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,703 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0121A |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0121A | | Number of Individuals Covered | 172 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $3,411 | | 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 $22,735 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,411 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12222727 |
| Policy instance | 1 |
| Insurance contract or identification number | 12222727 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1,137 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,029 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,137 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051092 |
| Policy instance | 2 |
| Insurance contract or identification number | W0051092 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $778,647 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603430 |
| Policy instance | 3 |
| Insurance contract or identification number | 603430 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $-12,328 | | Total amount of fees paid to insurance company | USD $750 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $630,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 750 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00025693 |
| Policy instance | 4 |
| Insurance contract or identification number | ER00025693 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $8,890 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $44,684 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,369 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0121A |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0121A | | Number of Individuals Covered | 174 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $3,439 | | 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 $22,929 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,439 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603430 |
| Policy instance | 3 |
| Insurance contract or identification number | 603430 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $12,375 | | Total amount of fees paid to insurance company | USD $1,193 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $655,323 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,144 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051092 |
| Policy instance | 2 |
| Insurance contract or identification number | W0051092 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $3,262 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $791,759 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,262 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12222727 |
| Policy instance | 1 |
| Insurance contract or identification number | 12222727 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $1,165 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,963 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $635 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0121A |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0121A | | Number of Individuals Covered | 164 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $2,197 | | 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 $14,641 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,589 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00025693 |
| Policy instance | 4 |
| Insurance contract or identification number | ER00025693 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $1,242 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $9,840 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,242 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603430 |
| Policy instance | 3 |
| Insurance contract or identification number | 603430 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $40,638 | | Total amount of fees paid to insurance company | USD $1,512 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $819,916 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | CP00047180 |
| Policy instance | 5 |
| Insurance contract or identification number | CP00047180 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $15,305 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER,CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $82,974 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12222727 |
| Policy instance | 1 |
| Insurance contract or identification number | 12222727 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $1,162 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,866 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051092 |
| Policy instance | 2 |
| Insurance contract or identification number | W0051092 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $36,735 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $734,698 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0121A |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0121A | | Number of Individuals Covered | 172 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $2,177 | | Total amount of fees paid to insurance company | USD $290 | | 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 $14,516 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0121A |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0121A | | Number of Individuals Covered | 112 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $2,094 | | Total amount of fees paid to insurance company | USD $342 | | 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 $13,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,094 | | Amount paid for insurance broker fees | 342 | | Additional information about fees paid to insurance broker | OTHER COMPENSAION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603430 |
| Policy instance | 2 |
| Insurance contract or identification number | 603430 | | Number of Individuals Covered | 85 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $27,349 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $552,949 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,349 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12222727 |
| Policy instance | 3 |
| Insurance contract or identification number | 12222727 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $1,111 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,154 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,111 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051092 |
| Policy instance | 1 |
| Insurance contract or identification number | W0051092 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $31,132 | | Total amount of fees paid to insurance company | USD $10,460 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $622,645 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,132 | | Amount paid for insurance broker fees | 10460 | | Additional information about fees paid to insurance broker | WELLNESS PAYMENT BONUS OVERRIDE ALLOCATION | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | H12197/932344 |
| Policy instance | 1 |
| Insurance contract or identification number | H12197/932344 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $36,213 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $724,262 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,391 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603430 |
| Policy instance | 2 |
| Insurance contract or identification number | 603430 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $24,080 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $485,758 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,363 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0121A |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0121A | | Number of Individuals Covered | 113 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $1,937 | | Total amount of fees paid to insurance company | USD $163 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,912 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,299 | | Amount paid for insurance broker fees | 163 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12222727 |
| Policy instance | 4 |
| Insurance contract or identification number | 12222727 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $1,138 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $913 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | H12197, 932344 |
| Policy instance | 1 |
| Insurance contract or identification number | H12197, 932344 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $34,064 | | Total amount of fees paid to insurance company | USD $3,597 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $677,259 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,064 | | Amount paid for insurance broker fees | 3597 | | Additional information about fees paid to insurance broker | BONUS OVERRIDE ALLOCATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603430 |
| Policy instance | 2 |
| Insurance contract or identification number | 603430 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $20,539 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $448,865 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,539 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000121A |
| Policy instance | 3 |
| Insurance contract or identification number | G000121A | | Number of Individuals Covered | 138 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $813 | | Total amount of fees paid to insurance company | USD $323 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,420 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $813 | | Amount paid for insurance broker fees | 323 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0121A |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0121A | | Number of Individuals Covered | 19 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $518 | | Total amount of fees paid to insurance company | USD $178 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,455 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $518 | | Amount paid for insurance broker fees | 178 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0121A |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL0121A | | Number of Individuals Covered | 8 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $665 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $665 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | H12197, 932344 |
| Policy instance | 6 |
| Insurance contract or identification number | H12197, 932344 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $1,098 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,783 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,098 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12222727 |
| Policy instance | 6 |
| Insurance contract or identification number | 12222727 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $1,041 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,161 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,041 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0121A |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL0121A | | Number of Individuals Covered | 9 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $619 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,128 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $619 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0121A |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0121A | | Number of Individuals Covered | 19 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $611 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $611 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000121A |
| Policy instance | 3 |
| Insurance contract or identification number | G000121A | | Number of Individuals Covered | 166 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $1,174 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,174 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603430 |
| Policy instance | 2 |
| Insurance contract or identification number | 603430 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $13,928 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $281,424 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,928 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | 65845A |
| Policy instance | 1 |
| Insurance contract or identification number | 65845A | | Number of Individuals Covered | 68 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $36,194 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,194 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
