SCHEIDT & BACHMANN USA, INC. has sponsored the creation of one or more 401k plans.
Additional information about SCHEIDT & BACHMANN USA, INC.
Submission information for form 5500 for 401k plan SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN
401k plan membership statisitcs for SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN
Measure | Date | Value |
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2021: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-07-01 | 179 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 179 |
Number of retired or separated participants receiving benefits | 2021-07-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
Total of all active and inactive participants | 2021-07-01 | 179 |
2020: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-07-01 | 179 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 179 |
Number of retired or separated participants receiving benefits | 2020-07-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 0 |
Total of all active and inactive participants | 2020-07-01 | 179 |
2019: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-07-01 | 179 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 179 |
Total of all active and inactive participants | 2019-07-01 | 179 |
Total participants | 2019-07-01 | 179 |
2018: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-07-01 | 111 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 179 |
Total of all active and inactive participants | 2018-07-01 | 179 |
Total participants | 2018-07-01 | 179 |
2017: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-07-01 | 161 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 111 |
Total of all active and inactive participants | 2017-07-01 | 111 |
Total participants | 2017-07-01 | 111 |
2016: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-07-01 | 164 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 161 |
Total of all active and inactive participants | 2016-07-01 | 161 |
Total participants | 2016-07-01 | 161 |
2015: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-07-01 | 118 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 164 |
Total of all active and inactive participants | 2015-07-01 | 164 |
Total participants | 2015-07-01 | 164 |
2014: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-07-01 | 158 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 118 |
Total of all active and inactive participants | 2014-07-01 | 118 |
Total participants | 2014-07-01 | 118 |
2013: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-07-01 | 142 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 158 |
Total of all active and inactive participants | 2013-07-01 | 158 |
Total participants | 2013-07-01 | 158 |
2012: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-07-01 | 134 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 142 |
Total of all active and inactive participants | 2012-07-01 | 142 |
Total participants | 2012-07-01 | 142 |
2011: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-07-01 | 134 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 133 |
Total of all active and inactive participants | 2011-07-01 | 133 |
Total participants | 2011-07-01 | 133 |
2009: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-07-01 | 141 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 135 |
Total of all active and inactive participants | 2009-07-01 | 135 |
Total participants | 2009-07-01 | 135 |
2008: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2008 401k membership |
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Total participants, beginning-of-year | 2008-07-01 | 133 |
Total number of active participants reported on line 7a of the Form 5500 | 2008-07-01 | 141 |
Total of all active and inactive participants | 2008-07-01 | 141 |
Total participants | 2008-07-01 | 141 |
Total participants, beginning-of-year | 2008-01-01 | 141 |
Total number of active participants reported on line 7a of the Form 5500 | 2008-01-01 | 133 |
Total of all active and inactive participants | 2008-01-01 | 133 |
Total participants | 2008-01-01 | 133 |
2007: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2007 401k membership |
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Total participants, beginning-of-year | 2007-01-01 | 148 |
Total number of active participants reported on line 7a of the Form 5500 | 2007-01-01 | 141 |
Total of all active and inactive participants | 2007-01-01 | 141 |
Total participants | 2007-01-01 | 141 |
2006: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2006 401k membership |
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Total participants, beginning-of-year | 2006-01-01 | 136 |
Total number of active participants reported on line 7a of the Form 5500 | 2006-01-01 | 148 |
Total of all active and inactive participants | 2006-01-01 | 148 |
Total participants | 2006-01-01 | 148 |
2021: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2021 form 5500 responses |
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2021-07-01 | Type of plan entity | Single employer plan |
2021-07-01 | Submission has been amended | No |
2021-07-01 | This submission is the final filing | No |
2021-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-07-01 | Plan is a collectively bargained plan | No |
2021-07-01 | Plan funding arrangement – Insurance | Yes |
2021-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-07-01 | Plan benefit arrangement – Insurance | Yes |
2021-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2020 form 5500 responses |
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2020-07-01 | Type of plan entity | Single employer plan |
2020-07-01 | Submission has been amended | No |
2020-07-01 | This submission is the final filing | No |
2020-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-07-01 | Plan is a collectively bargained plan | No |
2020-07-01 | Plan funding arrangement – Insurance | Yes |
2020-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-07-01 | Plan benefit arrangement – Insurance | Yes |
2020-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2019 form 5500 responses |
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2019-07-01 | Type of plan entity | Single employer plan |
2019-07-01 | Submission has been amended | No |
2019-07-01 | This submission is the final filing | No |
2019-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-07-01 | Plan is a collectively bargained plan | No |
2019-07-01 | Plan funding arrangement – Insurance | Yes |
2019-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-07-01 | Plan benefit arrangement – Insurance | Yes |
2019-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2018 form 5500 responses |
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2018-07-01 | Type of plan entity | Single employer plan |
2018-07-01 | Submission has been amended | No |
2018-07-01 | This submission is the final filing | No |
2018-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-07-01 | Plan is a collectively bargained plan | No |
2018-07-01 | Plan funding arrangement – Insurance | Yes |
2018-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-07-01 | Plan benefit arrangement – Insurance | Yes |
2018-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2017: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2017 form 5500 responses |
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2017-07-01 | Type of plan entity | Single employer plan |
2017-07-01 | Submission has been amended | No |
2017-07-01 | This submission is the final filing | No |
2017-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-07-01 | Plan is a collectively bargained plan | No |
2017-07-01 | Plan funding arrangement – Insurance | Yes |
2017-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-07-01 | Plan benefit arrangement – Insurance | Yes |
2017-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2016: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2016 form 5500 responses |
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2016-07-01 | Type of plan entity | Single employer plan |
2016-07-01 | Submission has been amended | No |
2016-07-01 | This submission is the final filing | No |
2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-07-01 | Plan is a collectively bargained plan | No |
2016-07-01 | Plan funding arrangement – Insurance | Yes |
2016-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2016-07-01 | Plan benefit arrangement – Insurance | Yes |
2016-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2015: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2015 form 5500 responses |
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2015-07-01 | Type of plan entity | Single employer plan |
2015-07-01 | Submission has been amended | No |
2015-07-01 | This submission is the final filing | No |
2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-07-01 | Plan is a collectively bargained plan | No |
2015-07-01 | Plan funding arrangement – Insurance | Yes |
2015-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2015-07-01 | Plan benefit arrangement – Insurance | Yes |
2015-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2014: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2014 form 5500 responses |
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2014-07-01 | Type of plan entity | Single employer plan |
2014-07-01 | Submission has been amended | No |
2014-07-01 | This submission is the final filing | No |
2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-07-01 | Plan is a collectively bargained plan | No |
2014-07-01 | Plan funding arrangement – Insurance | Yes |
2014-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2014-07-01 | Plan benefit arrangement – Insurance | Yes |
2014-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2013: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2013 form 5500 responses |
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2013-07-01 | Type of plan entity | Single employer plan |
2013-07-01 | Submission has been amended | No |
2013-07-01 | This submission is the final filing | No |
2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-07-01 | Plan is a collectively bargained plan | No |
2013-07-01 | Plan funding arrangement – Insurance | Yes |
2013-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2013-07-01 | Plan benefit arrangement – Insurance | Yes |
2013-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2012: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2012 form 5500 responses |
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2012-07-01 | Type of plan entity | Single employer plan |
2012-07-01 | Submission has been amended | No |
2012-07-01 | This submission is the final filing | No |
2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-07-01 | Plan is a collectively bargained plan | No |
2012-07-01 | Plan funding arrangement – Insurance | Yes |
2012-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2012-07-01 | Plan benefit arrangement – Insurance | Yes |
2012-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2011: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2011 form 5500 responses |
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2011-07-01 | Type of plan entity | Single employer plan |
2011-07-01 | Submission has been amended | No |
2011-07-01 | This submission is the final filing | No |
2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-07-01 | Plan is a collectively bargained plan | No |
2011-07-01 | Plan funding arrangement – Insurance | Yes |
2011-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2011-07-01 | Plan benefit arrangement – Insurance | Yes |
2011-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2009: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2009 form 5500 responses |
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2009-07-01 | Type of plan entity | Single employer plan |
2009-07-01 | Submission has been amended | No |
2009-07-01 | This submission is the final filing | No |
2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2009-07-01 | Plan is a collectively bargained plan | No |
2009-07-01 | Plan funding arrangement – Insurance | Yes |
2009-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2009-07-01 | Plan benefit arrangement – Insurance | Yes |
2009-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2008: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2008 form 5500 responses |
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2008-07-01 | Type of plan entity | Single employer plan |
2008-07-01 | Submission has been amended | No |
2008-07-01 | This submission is the final filing | No |
2008-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2008-07-01 | Plan is a collectively bargained plan | No |
2008-07-01 | Plan funding arrangement – Insurance | Yes |
2008-07-01 | Plan benefit arrangement – Insurance | Yes |
2008-01-01 | Type of plan entity | Single employer plan |
2008-01-01 | Submission has been amended | No |
2008-01-01 | This submission is the final filing | No |
2008-01-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2008-01-01 | Plan is a collectively bargained plan | No |
2008-01-01 | Plan funding arrangement – Insurance | Yes |
2008-01-01 | Plan benefit arrangement – Insurance | Yes |
2007: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2007 form 5500 responses |
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2007-01-01 | Type of plan entity | Single employer plan |
2007-01-01 | Submission has been amended | No |
2007-01-01 | This submission is the final filing | No |
2007-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2007-01-01 | Plan is a collectively bargained plan | No |
2007-01-01 | Plan funding arrangement – Insurance | Yes |
2007-01-01 | Plan benefit arrangement – Insurance | Yes |
2006: SCHEIDT & BACHMANN USA, INC. CAFETERIA PLAN 2006 form 5500 responses |
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2006-01-01 | Type of plan entity | Single employer plan |
2006-01-01 | First time form 5500 has been submitted | Yes |
2006-01-01 | Submission has been amended | No |
2006-01-01 | This submission is the final filing | No |
2006-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2006-01-01 | Plan is a collectively bargained plan | No |
2006-01-01 | Plan funding arrangement – Insurance | Yes |
2006-01-01 | Plan benefit arrangement – Insurance | Yes |
HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 0 |
Policy instance | 4 |
Insurance contract or identification number | 0 | Number of Individuals Covered | 179 | Insurance policy start date | 2021-07-01 | Insurance policy end date | 2022-06-30 | 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 $7,411 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 39454 |
Policy instance | 3 |
Insurance contract or identification number | 39454 | Number of Individuals Covered | 29 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $7,814 | 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 $170,308 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,814 | Insurance broker organization code? | 3 |
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BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 4958097 |
Policy instance | 2 |
Insurance contract or identification number | 4958097 | Number of Individuals Covered | 344 | Insurance policy start date | 2021-07-01 | Insurance policy end date | 2022-06-30 | Total amount of commissions paid to insurance broker | USD $87,332 | Total amount of fees paid to insurance company | USD $7,040 | 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 | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $87,332 | Amount paid for insurance broker fees | 7040 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10007491001 |
Policy instance | 1 |
Insurance contract or identification number | 10007491001 | Number of Individuals Covered | 226 | Insurance policy start date | 2021-07-01 | Insurance policy end date | 2022-06-30 | Total amount of commissions paid to insurance broker | USD $1,512 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $13,871 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,512 | Insurance broker organization code? | 3 |
|
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10007491001 |
Policy instance | 1 |
Insurance contract or identification number | 10007491001 | Number of Individuals Covered | 251 | Insurance policy start date | 2020-07-01 | Insurance policy end date | 2021-06-30 | Total amount of commissions paid to insurance broker | USD $1,529 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $15,260 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,529 | Insurance broker organization code? | 3 |
|
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 4958097 |
Policy instance | 2 |
Insurance contract or identification number | 4958097 | Number of Individuals Covered | 383 | Insurance policy start date | 2020-07-01 | Insurance policy end date | 2021-06-30 | Total amount of commissions paid to insurance broker | USD $79,925 | 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 | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $79,925 | Insurance broker organization code? | 3 |
|
HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 0 |
Policy instance | 4 |
Insurance contract or identification number | 0 | Number of Individuals Covered | 179 | Insurance policy start date | 2020-07-01 | Insurance policy end date | 2021-06-30 | 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 $4,833 | 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: 0000 ) |
Policy contract number | 39454 |
Policy instance | 3 |
Insurance contract or identification number | 39454 | Number of Individuals Covered | 34 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $8,281 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $166,186 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,281 | Insurance broker organization code? | 3 |
|
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10007491001 |
Policy instance | 1 |
Insurance contract or identification number | 10007491001 | Number of Individuals Covered | 244 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2020-06-30 | Total amount of commissions paid to insurance broker | USD $1,467 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $13,447 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,467 | Insurance broker organization code? | 3 |
|
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 39454 |
Policy instance | 4 |
Insurance contract or identification number | 39454 | Number of Individuals Covered | 27 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $8,281 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $166,189 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,281 | Insurance broker organization code? | 3 |
|
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 4958097 |
Policy instance | 2 |
Insurance contract or identification number | 4958097 | Number of Individuals Covered | 327 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2020-06-30 | Total amount of commissions paid to insurance broker | USD $75,948 | Total amount of fees paid to insurance company | USD $9,295 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $75,948 | Amount paid for insurance broker fees | 9295 | Additional information about fees paid to insurance broker | OTHER COMMISSION | Insurance broker organization code? | 3 |
|
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 4958097 |
Policy instance | 3 |
Insurance contract or identification number | 4958097 | Number of Individuals Covered | 381 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2020-06-30 | Total amount of commissions paid to insurance broker | USD $5,752 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,752 | Insurance broker organization code? | 3 |
|
HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | |
Policy instance | 5 |
Number of Individuals Covered | 179 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2020-06-30 | Total amount of commissions paid to insurance broker | 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 | 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 $2,041 | 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 | 39454 |
Policy instance | 4 |
Insurance contract or identification number | 39454 | Number of Individuals Covered | 30 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $8,515 | 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 $163,797 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,515 | Insurance broker organization code? | 3 |
|
HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 233080019 |
Policy instance | 5 |
Insurance contract or identification number | 233080019 | Number of Individuals Covered | 179 | Insurance policy start date | 2018-07-01 | Insurance policy end date | 2019-06-30 | Total amount of commissions paid to insurance broker | 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 | 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 $4,726 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 4958097 |
Policy instance | 2 |
Insurance contract or identification number | 4958097 | Number of Individuals Covered | 391 | Insurance policy start date | 2018-07-01 | Insurance policy end date | 2019-06-30 | Total amount of commissions paid to insurance broker | USD $5,710 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,710 | Insurance broker organization code? | 3 |
|
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 4958097 |
Policy instance | 1 |
Insurance contract or identification number | 4958097 | Number of Individuals Covered | 333 | Insurance policy start date | 2018-07-01 | Insurance policy end date | 2019-06-30 | Total amount of commissions paid to insurance broker | USD $78,052 | Total amount of fees paid to insurance company | USD $11,600 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $78,052 | Amount paid for insurance broker fees | 11600 | Additional information about fees paid to insurance broker | OTHER COMMISSION | Insurance broker organization code? | 3 |
|
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10007491001 |
Policy instance | 3 |
Insurance contract or identification number | 10007491001 | Number of Individuals Covered | 252 | Insurance policy start date | 2018-07-01 | Insurance policy end date | 2019-06-30 | Total amount of commissions paid to insurance broker | USD $1,391 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $14,391 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,391 | Insurance broker organization code? | 3 |
|
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10007491001 |
Policy instance | 1 |
Insurance contract or identification number | 10007491001 | Number of Individuals Covered | 218 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2018-06-30 | Total amount of commissions paid to insurance broker | USD $1,328 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $14,244 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,328 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
|
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 4958097 |
Policy instance | 2 |
Insurance contract or identification number | 4958097 | Number of Individuals Covered | 334 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2018-06-30 | Total amount of commissions paid to insurance broker | USD $77,723 | Total amount of fees paid to insurance company | USD $5,110 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $77,723 | Amount paid for insurance broker fees | 5110 | Additional information about fees paid to insurance broker | OTHER COMMISSION | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
|
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 39454 |
Policy instance | 4 |
Insurance contract or identification number | 39454 | Number of Individuals Covered | 30 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $5,795 | 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 $110,383 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,795 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
|
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 4958097 |
Policy instance | 3 |
Insurance contract or identification number | 4958097 | Number of Individuals Covered | 386 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2018-06-30 | Total amount of commissions paid to insurance broker | USD $5,572 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,572 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
|
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 941340523 |
Policy instance | 4 |
Insurance contract or identification number | 941340523 | Number of Individuals Covered | 33 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $7,978 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $160,186 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,978 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
|
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 1000749 |
Policy instance | 3 |
Insurance contract or identification number | 1000749 | Number of Individuals Covered | 175 | Insurance policy start date | 2015-07-01 | Insurance policy end date | 2016-06-30 | Total amount of commissions paid to insurance broker | USD $869 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $9,520 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $869 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
|
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 4958097 |
Policy instance | 2 |
Insurance contract or identification number | 4958097 | Number of Individuals Covered | 164 | Insurance policy start date | 2015-07-01 | Insurance policy end date | 2016-06-30 | Total amount of commissions paid to insurance broker | USD $5,869 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,869 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH, INC. |
|
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 4958097 |
Policy instance | 1 |
Insurance contract or identification number | 4958097 | Number of Individuals Covered | 144 | Insurance policy start date | 2015-07-01 | Insurance policy end date | 2016-06-30 | Total amount of commissions paid to insurance broker | USD $79,978 | Total amount of fees paid to insurance company | USD $14,100 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $79,978 | Amount paid for insurance broker fees | 14100 | Additional information about fees paid to insurance broker | OTHER COMMISSION | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH, INC. |
|
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 39454 |
Policy instance | 4 |
Insurance contract or identification number | 39454 | Number of Individuals Covered | 30 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $6,870 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | 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 $137,986 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,870 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 030117075526 |
Policy instance | 2 |
Insurance contract or identification number | 030117075526 | Number of Individuals Covered | 118 | Insurance policy start date | 2014-07-01 | Insurance policy end date | 2015-06-30 | Total amount of commissions paid to insurance broker | USD $20,217 | Total amount of fees paid to insurance company | USD $279 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $577,642 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,217 | Amount paid for insurance broker fees | 279 | Additional information about fees paid to insurance broker | OTHER COMPENSATION PAID | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
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TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 ) |
Policy contract number | 030117075526 |
Policy instance | 1 |
Insurance contract or identification number | 030117075526 | Number of Individuals Covered | 275 | Insurance policy start date | 2014-07-01 | Insurance policy end date | 2015-06-30 | Total amount of commissions paid to insurance broker | USD $60,288 | Total amount of fees paid to insurance company | USD $977 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,722,527 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $60,288 | Amount paid for insurance broker fees | 977 | Additional information about fees paid to insurance broker | OTHER COMPENSATION PAID | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
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DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
Policy contract number | 003259 |
Policy instance | 3 |
Insurance contract or identification number | 003259 | Number of Individuals Covered | 444 | Insurance policy start date | 2014-07-01 | Insurance policy end date | 2015-06-30 | Total amount of commissions paid to insurance broker | USD $6,250 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $191,391 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,250 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 64097000 |
Policy instance | 2 |
Insurance contract or identification number | 64097000 | Number of Individuals Covered | 28 | Insurance policy start date | 2013-07-01 | Insurance policy end date | 2014-06-30 | Total amount of commissions paid to insurance broker | USD $14,401 | Total amount of fees paid to insurance company | USD $231 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $381,423 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,401 | Amount paid for insurance broker fees | 231 | Additional information about fees paid to insurance broker | OTHER BROKER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 42864000 |
Policy instance | 1 |
Insurance contract or identification number | 42864000 | Number of Individuals Covered | 112 | Insurance policy start date | 2013-07-01 | Insurance policy end date | 2014-06-30 | Total amount of commissions paid to insurance broker | USD $58,571 | Total amount of fees paid to insurance company | USD $935 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,157,517 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $58,571 | Amount paid for insurance broker fees | 935 | Additional information about fees paid to insurance broker | OTHER BROKER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
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DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
Policy contract number | 0032590001 |
Policy instance | 3 |
Insurance contract or identification number | 0032590001 | Number of Individuals Covered | 413 | Insurance policy start date | 2013-07-01 | Insurance policy end date | 2014-06-30 | Total amount of commissions paid to insurance broker | USD $5,233 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $177,532 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,233 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 39454 |
Policy instance | 4 |
Insurance contract or identification number | 39454 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 64097000 |
Policy instance | 2 |
Insurance contract or identification number | 64097000 | Number of Individuals Covered | 29 | Insurance policy start date | 2012-07-01 | Insurance policy end date | 2013-06-30 | Total amount of commissions paid to insurance broker | USD $11,211 | Total amount of fees paid to insurance company | USD $287 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $350,353 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,211 | Amount paid for insurance broker fees | 287 | Additional information about fees paid to insurance broker | OTHER BROKER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH, INC. |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 39454 |
Policy instance | 4 |
Insurance contract or identification number | 39454 | Number of Individuals Covered | 25 | Insurance policy start date | 2012-07-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $2,695 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $54,136 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,695 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH, INC. |
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DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
Policy contract number | 003259 |
Policy instance | 3 |
Insurance contract or identification number | 003259 | Number of Individuals Covered | 399 | Insurance policy start date | 2012-07-01 | Insurance policy end date | 2013-06-30 | Total amount of commissions paid to insurance broker | USD $6,441 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $175,076 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,441 | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH INC. |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 42864000 |
Policy instance | 1 |
Insurance contract or identification number | 42864000 | Number of Individuals Covered | 113 | Insurance policy start date | 2012-07-01 | Insurance policy end date | 2013-06-30 | Total amount of commissions paid to insurance broker | USD $44,455 | Total amount of fees paid to insurance company | USD $1,069 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,386,101 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $44,455 | Amount paid for insurance broker fees | 1069 | Additional information about fees paid to insurance broker | OTHER BROKER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | FRED C. CHURCH, INC. |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 39454 |
Policy instance | 4 |
Insurance contract or identification number | 39454 | Number of Individuals Covered | 24 | Insurance policy start date | 2011-07-01 | Insurance policy end date | 2012-06-30 | Total amount of commissions paid to insurance broker | USD $5,476 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $77,115 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 42864000 |
Policy instance | 1 |
Insurance contract or identification number | 42864000 | Number of Individuals Covered | 104 | Insurance policy start date | 2011-07-01 | Insurance policy end date | 2012-06-30 | Total amount of commissions paid to insurance broker | USD $41,760 | Total amount of fees paid to insurance company | USD $5,632 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,193,130 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 64097000 |
Policy instance | 2 |
Insurance contract or identification number | 64097000 | Number of Individuals Covered | 29 | Insurance policy start date | 2011-07-01 | Insurance policy end date | 2012-06-30 | Total amount of commissions paid to insurance broker | USD $11,832 | Total amount of fees paid to insurance company | USD $1,500 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $338,055 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
Policy contract number | 003259 |
Policy instance | 3 |
Insurance contract or identification number | 003259 | Number of Individuals Covered | 383 | Insurance policy start date | 2011-07-01 | Insurance policy end date | 2012-06-30 | Total amount of commissions paid to insurance broker | USD $5,615 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $166,080 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 42864000 |
Policy instance | 1 |
Insurance contract or identification number | 42864000 | Number of Individuals Covered | 107 | Insurance policy start date | 2010-07-01 | Insurance policy end date | 2011-06-30 | Total amount of commissions paid to insurance broker | USD $38,829 | Total amount of fees paid to insurance company | USD $956 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,109,405 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 64097000 |
Policy instance | 2 |
Insurance contract or identification number | 64097000 | Number of Individuals Covered | 27 | Insurance policy start date | 2010-07-01 | Insurance policy end date | 2011-06-30 | Total amount of commissions paid to insurance broker | USD $9,125 | Total amount of fees paid to insurance company | USD $234 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $260,708 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 39454 |
Policy instance | 4 |
Insurance contract or identification number | 39454 | Number of Individuals Covered | 23 | Insurance policy start date | 2010-07-01 | Insurance policy end date | 2011-06-30 | Total amount of commissions paid to insurance broker | USD $5,093 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $111,277 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
Policy contract number | 003259 |
Policy instance | 3 |
Insurance contract or identification number | 003259 | Number of Individuals Covered | 361 | Insurance policy start date | 2010-07-01 | Insurance policy end date | 2011-06-30 | Total amount of commissions paid to insurance broker | USD $5,626 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $163,896 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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