SUPREME CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SUPREME CORPORATION GROUP INSURANCE PLAN
| Measure | Date | Value |
|---|
| 2018: SUPREME CORPORATION GROUP INSURANCE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 1,295 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 0 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| 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 | 0 |
| 2017: SUPREME CORPORATION GROUP INSURANCE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 1,291 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 1,295 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| 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 | 1,295 |
| 2016: SUPREME CORPORATION GROUP INSURANCE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 1,262 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 1,288 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 1,291 |
| 2015: SUPREME CORPORATION GROUP INSURANCE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 1,264 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 1,256 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 16 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 1,272 |
| 2014: SUPREME CORPORATION GROUP INSURANCE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 1,446 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 1,241 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 23 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 1,264 |
| 2013: SUPREME CORPORATION GROUP INSURANCE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-05-01 | 1,527 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 1,424 |
| Number of retired or separated participants receiving benefits | 2013-05-01 | 8 |
| Number of other retired or separated participants entitled to future benefits | 2013-05-01 | 0 |
| Total of all active and inactive participants | 2013-05-01 | 1,432 |
| 2012: SUPREME CORPORATION GROUP INSURANCE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-05-01 | 1,437 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 1,518 |
| Number of retired or separated participants receiving benefits | 2012-05-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2012-05-01 | 0 |
| Total of all active and inactive participants | 2012-05-01 | 1,527 |
| 2011: SUPREME CORPORATION GROUP INSURANCE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-05-01 | 967 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-05-01 | 1,429 |
| Number of retired or separated participants receiving benefits | 2011-05-01 | 8 |
| Number of other retired or separated participants entitled to future benefits | 2011-05-01 | 0 |
| Total of all active and inactive participants | 2011-05-01 | 1,437 |
| 2010: SUPREME CORPORATION GROUP INSURANCE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-05-01 | 879 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-05-01 | 960 |
| Number of retired or separated participants receiving benefits | 2010-05-01 | 7 |
| Total of all active and inactive participants | 2010-05-01 | 967 |
| Total participants | 2010-05-01 | 967 |
| 2009: SUPREME CORPORATION GROUP INSURANCE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-05-01 | 1,163 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-05-01 | 867 |
| Number of retired or separated participants receiving benefits | 2009-05-01 | 12 |
| Total of all active and inactive participants | 2009-05-01 | 879 |
| Total participants | 2009-05-01 | 879 |
| 2018: SUPREME CORPORATION GROUP INSURANCE PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | This submission is the final filing | Yes |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: SUPREME CORPORATION GROUP INSURANCE PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 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 |
| 2016: SUPREME CORPORATION GROUP INSURANCE PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: SUPREME CORPORATION GROUP INSURANCE PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: SUPREME CORPORATION GROUP INSURANCE PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: SUPREME CORPORATION GROUP INSURANCE PLAN 2013 form 5500 responses |
|---|
| 2013-05-01 | Type of plan entity | Single employer plan |
| 2013-05-01 | Submission has been amended | No |
| 2013-05-01 | This submission is the final filing | No |
| 2013-05-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2013-05-01 | Plan is a collectively bargained plan | No |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: SUPREME CORPORATION GROUP INSURANCE PLAN 2012 form 5500 responses |
|---|
| 2012-05-01 | Type of plan entity | Single employer plan |
| 2012-05-01 | Submission has been amended | No |
| 2012-05-01 | This submission is the final filing | No |
| 2012-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-05-01 | Plan is a collectively bargained plan | No |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: SUPREME CORPORATION GROUP INSURANCE PLAN 2011 form 5500 responses |
|---|
| 2011-05-01 | Type of plan entity | Single employer plan |
| 2011-05-01 | Submission has been amended | No |
| 2011-05-01 | This submission is the final filing | No |
| 2011-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-05-01 | Plan is a collectively bargained plan | No |
| 2011-05-01 | Plan funding arrangement – Insurance | Yes |
| 2011-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: SUPREME CORPORATION GROUP INSURANCE PLAN 2010 form 5500 responses |
|---|
| 2010-05-01 | Type of plan entity | Single employer plan |
| 2010-05-01 | Submission has been amended | No |
| 2010-05-01 | This submission is the final filing | No |
| 2010-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-05-01 | Plan is a collectively bargained plan | No |
| 2010-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: SUPREME CORPORATION GROUP INSURANCE PLAN 2009 form 5500 responses |
|---|
| 2009-05-01 | Type of plan entity | Single employer plan |
| 2009-05-01 | Submission has been amended | No |
| 2009-05-01 | This submission is the final filing | No |
| 2009-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-05-01 | Plan is a collectively bargained plan | No |
| 2009-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
| Policy contract number | 5407 |
| Policy instance | 6 |
| Insurance contract or identification number | 5407 | | Number of Individuals Covered | 1626 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 213008 |
| Policy instance | 2 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1316 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $18,454 | | Total amount of fees paid to insurance company | USD $2,914 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $137,559 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,454 | | Amount paid for insurance broker fees | 2914 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | GIBSON INSURANCE AGENCY INC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0557306 |
| Policy instance | 3 |
| Insurance contract or identification number | R0557306 | | Number of Individuals Covered | 672 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $26,634 | | Total amount of fees paid to insurance company | USD $1,878 | | Other welfare benefits provided | CRITICAL ILLNESS, ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $187,973 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,502 | | Amount paid for insurance broker fees | 1371 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | BOUDREAUX, BEAU, DAVID |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010329744 |
| Policy instance | 1 |
| Insurance contract or identification number | 0010329744 | | Number of Individuals Covered | 576 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $17,843 | | Total amount of fees paid to insurance company | USD $239 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY WORKSITE BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $161,721 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,061 | | Amount paid for insurance broker fees | 183 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | NFP INSURANCE SERVICES, INC. |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 213008 |
| Policy instance | 5 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1295 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $431,910 | | 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 | 142193 |
| Policy instance | 4 |
| Insurance contract or identification number | 142193 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2016-05-01 | | Insurance policy end date | 2017-04-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $318,825 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 213008 |
| Policy instance | 1 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1256 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $16,048 | | Total amount of fees paid to insurance company | USD $7,643 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $129,475 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,048 | | Amount paid for insurance broker fees | 7643 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | GIBSON INSURANCE AGENCY INC. |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 213008 |
| Policy instance | 3 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1303 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,640 | | 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 | 142193 |
| Policy instance | 2 |
| Insurance contract or identification number | 142193 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | 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 $308,901 | | 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 | 142193 |
| Policy instance | 2 |
| Insurance contract or identification number | 142193 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | 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 $398,663 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 213008 |
| Policy instance | 3 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1075 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $70,270 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 213008 |
| Policy instance | 1 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1241 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $13,592 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $134,902 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,592 | | Insurance broker organization code? | 3 | | Insurance broker name | GIBSON INSURANCE AGENCY INC. |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 213008 |
| Policy instance | 1 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1424 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $5,997 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $118,046 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,997 | | Insurance broker organization code? | 3 | | Insurance broker name | GIBSON INSURANCE AGENCY INC. |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 213008 |
| Policy instance | 3 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1088 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,019 | | 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 | 142193 |
| Policy instance | 2 |
| Insurance contract or identification number | 142193 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 213008 |
| Policy instance | 3 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1518 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $5,791 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $139,451 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,791 | | Insurance broker organization code? | 3 | | Insurance broker name | GIBSON INSURANCE AGENCY INC. |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 142193 |
| Policy instance | 2 |
| Insurance contract or identification number | 142193 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | 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 $355,768 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 213008 |
| Policy instance | 1 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1059 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,034 | | 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 | 142193 |
| Policy instance | 1 |
| Insurance contract or identification number | 142193 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | 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 $389,602 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 213008 |
| Policy instance | 2 |
| Insurance contract or identification number | 213008 | | Number of Individuals Covered | 1429 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $5,239 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $78,329 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 03324140213008 |
| Policy instance | 4 |
| Insurance contract or identification number | 03324140213008 | | Number of Individuals Covered | 927 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of fees paid to insurance company | USD $603,891 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010004324 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010004324 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of fees paid to insurance company | USD $276 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000400001000 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $12,968 | | 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 | 142193 |
| Policy instance | 5 |
| Insurance contract or identification number | 142193 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010090362 |
| Policy instance | 1 |
| Insurance contract or identification number | 000010090362 | | Number of Individuals Covered | 973 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of fees paid to insurance company | USD $1,365 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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