401k Plan data: EVANS HOTELS, LLC WELFARE BENEFIT PLAN plan

EVANS HOTELS, LLC WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	EVANS HOTELS, LLC WELFARE BENEFIT PLAN
Plan identification number	501

EVANS HOTELS, LLC WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Other welfare benefit cover

401k Sponsoring company profile

EVANS HOTELS, LLC has sponsored the creation of one or more 401k plans.

Company Name: EVANS HOTELS, LLC

Employer identification number (EIN): 810750751

NAIC Classification: 721110
NAIC Description: Hotels (except Casino Hotels) and Motels

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EVANS HOTELS, LLC WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-03-01
501 2022-03-01
501 2021-03-01
501 2020-03-01
501 2019-03-01
501 2018-03-01
501 2017-03-01 JESSICA STEENBLOCK JESSICA STEENBLOCK 2018-12-13
501 2016-03-01 ELVIA FERNANDEZ

Plan Statistics for EVANS HOTELS, LLC WELFARE BENEFIT PLAN

401k plan membership statisitcs for EVANS HOTELS, LLC WELFARE BENEFIT PLAN

Measure Date Value
2023: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year 2023-03-01 851
Total number of active participants reported on line 7a of the Form 5500 2023-03-01 717
Number of retired or separated participants receiving benefits 2023-03-01 1
Number of other retired or separated participants entitled to future benefits 2023-03-01 0
Total of all active and inactive participants 2023-03-01 718
2022: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-03-01 905
Total number of active participants reported on line 7a of the Form 5500 2022-03-01 851
Number of retired or separated participants receiving benefits 2022-03-01 0
Number of other retired or separated participants entitled to future benefits 2022-03-01 0
Total of all active and inactive participants 2022-03-01 851
2021: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-03-01 595
Total number of active participants reported on line 7a of the Form 5500 2021-03-01 905
Number of retired or separated participants receiving benefits 2021-03-01 0
Number of other retired or separated participants entitled to future benefits 2021-03-01 0
Total of all active and inactive participants 2021-03-01 905
2020: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-03-01 899
Total number of active participants reported on line 7a of the Form 5500 2020-03-01 583
Number of retired or separated participants receiving benefits 2020-03-01 12
Number of other retired or separated participants entitled to future benefits 2020-03-01 0
Total of all active and inactive participants 2020-03-01 595
2019: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-03-01 875
Total number of active participants reported on line 7a of the Form 5500 2019-03-01 898
Number of retired or separated participants receiving benefits 2019-03-01 1
Number of other retired or separated participants entitled to future benefits 2019-03-01 0
Total of all active and inactive participants 2019-03-01 899
2018: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-03-01 978
Total number of active participants reported on line 7a of the Form 5500 2018-03-01 873
Number of retired or separated participants receiving benefits 2018-03-01 2
Number of other retired or separated participants entitled to future benefits 2018-03-01 0
Total of all active and inactive participants 2018-03-01 875
2017: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-03-01 980
Total number of active participants reported on line 7a of the Form 5500 2017-03-01 973
Number of retired or separated participants receiving benefits 2017-03-01 5
Number of other retired or separated participants entitled to future benefits 2017-03-01 0
Total of all active and inactive participants 2017-03-01 978
2016: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-03-01 893
Total number of active participants reported on line 7a of the Form 5500 2016-03-01 973
Number of retired or separated participants receiving benefits 2016-03-01 7
Number of other retired or separated participants entitled to future benefits 2016-03-01 0
Total of all active and inactive participants 2016-03-01 980

Measure	Date	Value
2023: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year	2023-03-01	851
Total number of active participants reported on line 7a of the Form 5500	2023-03-01	717
Number of retired or separated participants receiving benefits	2023-03-01	1
Number of other retired or separated participants entitled to future benefits	2023-03-01	0
Total of all active and inactive participants	2023-03-01	718
2022: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-03-01	905
Total number of active participants reported on line 7a of the Form 5500	2022-03-01	851
Number of retired or separated participants receiving benefits	2022-03-01	0
Number of other retired or separated participants entitled to future benefits	2022-03-01	0
Total of all active and inactive participants	2022-03-01	851
2021: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-03-01	595
Total number of active participants reported on line 7a of the Form 5500	2021-03-01	905
Number of retired or separated participants receiving benefits	2021-03-01	0
Number of other retired or separated participants entitled to future benefits	2021-03-01	0
Total of all active and inactive participants	2021-03-01	905
2020: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-03-01	899
Total number of active participants reported on line 7a of the Form 5500	2020-03-01	583
Number of retired or separated participants receiving benefits	2020-03-01	12
Number of other retired or separated participants entitled to future benefits	2020-03-01	0
Total of all active and inactive participants	2020-03-01	595
2019: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-03-01	875
Total number of active participants reported on line 7a of the Form 5500	2019-03-01	898
Number of retired or separated participants receiving benefits	2019-03-01	1
Number of other retired or separated participants entitled to future benefits	2019-03-01	0
Total of all active and inactive participants	2019-03-01	899
2018: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-03-01	978
Total number of active participants reported on line 7a of the Form 5500	2018-03-01	873
Number of retired or separated participants receiving benefits	2018-03-01	2
Number of other retired or separated participants entitled to future benefits	2018-03-01	0
Total of all active and inactive participants	2018-03-01	875
2017: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-03-01	980
Total number of active participants reported on line 7a of the Form 5500	2017-03-01	973
Number of retired or separated participants receiving benefits	2017-03-01	5
Number of other retired or separated participants entitled to future benefits	2017-03-01	0
Total of all active and inactive participants	2017-03-01	978
2016: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-03-01	893
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	973
Number of retired or separated participants receiving benefits	2016-03-01	7
Number of other retired or separated participants entitled to future benefits	2016-03-01	0
Total of all active and inactive participants	2016-03-01	980

Form 5500 Responses for EVANS HOTELS, LLC WELFARE BENEFIT PLAN

2023: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2023 form 5500 responses
2023-03-01	Type of plan entity	Single employer plan
2023-03-01	Submission has been amended	No
2023-03-01	This submission is the final filing	No
2023-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-03-01	Plan is a collectively bargained plan	No
2023-03-01	Plan funding arrangement – Insurance	Yes
2023-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-03-01	Plan benefit arrangement – Insurance	Yes
2023-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-03-01	Type of plan entity	Single employer plan
2022-03-01	Submission has been amended	No
2022-03-01	This submission is the final filing	No
2022-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-03-01	Plan is a collectively bargained plan	No
2022-03-01	Plan funding arrangement – Insurance	Yes
2022-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-03-01	Plan benefit arrangement – Insurance	Yes
2022-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-03-01	Type of plan entity	Single employer plan
2021-03-01	Submission has been amended	No
2021-03-01	This submission is the final filing	No
2021-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-03-01	Plan is a collectively bargained plan	No
2021-03-01	Plan funding arrangement – Insurance	Yes
2021-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-03-01	Plan benefit arrangement – Insurance	Yes
2021-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-03-01	Type of plan entity	Single employer plan
2020-03-01	Submission has been amended	No
2020-03-01	This submission is the final filing	No
2020-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-03-01	Plan is a collectively bargained plan	No
2020-03-01	Plan funding arrangement – Insurance	Yes
2020-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-03-01	Plan benefit arrangement – Insurance	Yes
2020-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-03-01	Type of plan entity	Single employer plan
2019-03-01	Submission has been amended	No
2019-03-01	This submission is the final filing	No
2019-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-03-01	Plan is a collectively bargained plan	No
2019-03-01	Plan funding arrangement – Insurance	Yes
2019-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-03-01	Plan benefit arrangement – Insurance	Yes
2019-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-03-01	Type of plan entity	Single employer plan
2018-03-01	Submission has been amended	No
2018-03-01	This submission is the final filing	No
2018-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-03-01	Plan is a collectively bargained plan	No
2018-03-01	Plan funding arrangement – Insurance	Yes
2018-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-03-01	Plan benefit arrangement – Insurance	Yes
2018-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-03-01	Type of plan entity	Single employer plan
2017-03-01	Submission has been amended	No
2017-03-01	This submission is the final filing	No
2017-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-03-01	Plan is a collectively bargained plan	No
2017-03-01	Plan funding arrangement – Insurance	Yes
2017-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-03-01	Plan benefit arrangement – Insurance	Yes
2017-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: EVANS HOTELS, LLC WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Submission has been amended	No
2016-03-01	This submission is the final filing	No
2016-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-03-01	Plan is a collectively bargained plan	No
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

115/116/117

Policy instance

Insurance contract or identification number	115/116/117
Number of Individuals Covered	294
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $24,670
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
Welfare Benefit Premiums Paid to Carrier	USD $822,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	105
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $2,175
Total amount of fees paid to insurance company	USD $1,222
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
Welfare Benefit Premiums Paid to Carrier	USD $25,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10105481

Policy instance

Insurance contract or identification number	10105481
Number of Individuals Covered	347
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $2,870
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 $31,199
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

L02451

Policy instance

Insurance contract or identification number	L02451
Number of Individuals Covered	823
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $13,656
Total amount of fees paid to insurance company	USD $3,368
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, ACCIDENT, CRITICAL ILLNESS AND HOSPITAL INDEMNITY
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 $55,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	162
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $8,521
Total amount of fees paid to insurance company	USD $4,734
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
Welfare Benefit Premiums Paid to Carrier	USD $103,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

1006415

Policy instance

Insurance contract or identification number	1006415
Number of Individuals Covered	359
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $85,984
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
Other welfare benefits provided	POS CONTRACT
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 $2,866,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

115/116/117

Policy instance

Insurance contract or identification number	115/116/117
Number of Individuals Covered	269
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $20,958
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
Welfare Benefit Premiums Paid to Carrier	USD $703,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,958
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	162
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $8,521
Total amount of fees paid to insurance company	USD $4,734
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
Welfare Benefit Premiums Paid to Carrier	USD $103,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,521
Amount paid for insurance broker fees	4734
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

L02451

Policy instance

Insurance contract or identification number	L02451
Number of Individuals Covered	851
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $19,773
Total amount of fees paid to insurance company	USD $3,096
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D. ACCIDENT, CRITICAL ILLNESS AND HOSPITAL INDEMNITY
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 $100,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,773
Amount paid for insurance broker fees	3096
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10105481

Policy instance

Insurance contract or identification number	10105481
Number of Individuals Covered	367
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $2,248
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 $19,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,248
Insurance broker organization code?	3

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

1006415

Policy instance

Insurance contract or identification number	1006415
Number of Individuals Covered	484
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $78,812
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
Other welfare benefits provided	POS CONTRACT
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 $2,627,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $78,812
Insurance broker organization code?	3

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	105
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $2,175
Total amount of fees paid to insurance company	USD $1,222
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
Welfare Benefit Premiums Paid to Carrier	USD $25,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,175
Amount paid for insurance broker fees	1222
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	115
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $6,650
Total amount of fees paid to insurance company	USD $3,695
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
Welfare Benefit Premiums Paid to Carrier	USD $74,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,650
Amount paid for insurance broker fees	3695
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

L02451

Policy instance

Insurance contract or identification number	L02451
Number of Individuals Covered	905
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $6,531
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D. ACCIDENT, CRITICAL ILLNESS AND HOSPITAL INDEMNITY
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 $35,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,531
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10105481

Policy instance

Insurance contract or identification number	10105481
Number of Individuals Covered	365
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $2,055
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 $20,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,055
Insurance broker organization code?	3

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	124
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $2,597
Total amount of fees paid to insurance company	USD $1,443
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
Welfare Benefit Premiums Paid to Carrier	USD $29,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,597
Amount paid for insurance broker fees	1443
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

1006415

Policy instance

Insurance contract or identification number	1006415
Number of Individuals Covered	411
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $72,558
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
Other welfare benefits provided	POS CONTRACT
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 $2,418,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,558
Insurance broker organization code?	3

SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

115/116/117

Policy instance

Insurance contract or identification number	115/116/117
Number of Individuals Covered	260
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $18,318
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
Welfare Benefit Premiums Paid to Carrier	USD $624,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,318
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10105481

Policy instance

Insurance contract or identification number	10105481
Number of Individuals Covered	352
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $2,593
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 $26,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,593
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

9392136

Policy instance

Insurance contract or identification number	9392136
Number of Individuals Covered	243
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $3,227
Total amount of fees paid to insurance company	USD $135
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $47,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,188
Amount paid for insurance broker fees	107
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

115/116/117

Policy instance

Insurance contract or identification number	115/116/117
Number of Individuals Covered	299
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $21,547
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
Welfare Benefit Premiums Paid to Carrier	USD $725,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,547
Insurance broker organization code?	3

NATIONAL HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 82538 )

Policy contract number

Y5688

Policy instance

Insurance contract or identification number	Y5688
Number of Individuals Covered	7
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $5,660
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 $188,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,660
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

097851

Policy instance

Insurance contract or identification number	097851
Number of Individuals Covered	219
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $8,930
Total amount of fees paid to insurance company	USD $1,191
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $49,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,930
Amount paid for insurance broker fees	1191
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

473190

Policy instance

Insurance contract or identification number	473190
Number of Individuals Covered	458
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $72,858
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,428,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,858
Insurance broker organization code?	3

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	124
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $3,349
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $36,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,349
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	106
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $7,937
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	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 $89,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,937
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

097850

Policy instance

Insurance contract or identification number	097850
Number of Individuals Covered	551
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $1,879
Total amount of fees paid to insurance company	USD $376
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $18,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,879
Amount paid for insurance broker fees	376
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0412866

Policy instance

Insurance contract or identification number	R0412866
Number of Individuals Covered	99
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $1,067
Total amount of fees paid to insurance company	USD $6
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	CRITICAL ILLNESS
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 $18,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $546
Insurance broker organization code?	3
Amount paid for insurance broker fees	6
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	134
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $6,611
Total amount of fees paid to insurance company	USD $3,624
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
Welfare Benefit Premiums Paid to Carrier	USD $88,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,611
Amount paid for insurance broker fees	3624
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

097851

Policy instance

Insurance contract or identification number	097851
Number of Individuals Covered	266
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $12,585
Total amount of fees paid to insurance company	USD $1,678
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $83,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,585
Amount paid for insurance broker fees	1678
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

115/116/117

Policy instance

Insurance contract or identification number	115/116/117
Number of Individuals Covered	404
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $26,360
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
Welfare Benefit Premiums Paid to Carrier	USD $878,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,360
Insurance broker organization code?	3

NATIONAL HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 82538 )

Policy contract number

Y5688

Policy instance

Insurance contract or identification number	Y5688
Number of Individuals Covered	6
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $5,957
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 $198,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,957
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

097850

Policy instance

Insurance contract or identification number	097850
Number of Individuals Covered	893
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $769
Total amount of fees paid to insurance company	USD $154
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $769
Amount paid for insurance broker fees	154
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10105481

Policy instance

Insurance contract or identification number	10105481
Number of Individuals Covered	524
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $2,827
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 $28,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,827
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0412866

Policy instance

Insurance contract or identification number	R0412866
Number of Individuals Covered	144
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $5,123
Total amount of fees paid to insurance company	USD $504
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	CRITICAL ILLNESS
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 $32,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,504
Amount paid for insurance broker fees	432
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

9392136

Policy instance

Insurance contract or identification number	9392136
Number of Individuals Covered	316
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $17,732
Total amount of fees paid to insurance company	USD $1,713
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $82,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,055
Amount paid for insurance broker fees	1466
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

473190

Policy instance

Insurance contract or identification number	473190
Number of Individuals Covered	591
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $84,221
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,807,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84,221
Insurance broker organization code?	3

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	191
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $3,498
Total amount of fees paid to insurance company	USD $1,754
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
Welfare Benefit Premiums Paid to Carrier	USD $42,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,498
Amount paid for insurance broker fees	1754
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

473190

Policy instance

Insurance contract or identification number	473190
Number of Individuals Covered	558
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $81,127
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,704,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $81,127
Insurance broker organization code?	3

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	212
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $4,074
Total amount of fees paid to insurance company	USD $2,081
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
Welfare Benefit Premiums Paid to Carrier	USD $44,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,074
Amount paid for insurance broker fees	2081
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10105481

Policy instance

Insurance contract or identification number	10105481
Number of Individuals Covered	466
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $2,637
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 $24,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,637
Insurance broker organization code?	3

NATIONAL HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 82538 )

Policy contract number

Y5688

Policy instance

Insurance contract or identification number	Y5688
Number of Individuals Covered	59
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $4,228
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $140,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,228
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	131
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $7,524
Total amount of fees paid to insurance company	USD $3,849
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
Welfare Benefit Premiums Paid to Carrier	USD $83,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,524
Amount paid for insurance broker fees	3849
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

097851

Policy instance

Insurance contract or identification number	097851
Number of Individuals Covered	244
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $7,212
Total amount of fees paid to insurance company	USD $1,004
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $42,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,212
Amount paid for insurance broker fees	1004
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

115/116/117

Policy instance

Insurance contract or identification number	115/116/117
Number of Individuals Covered	405
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $25,122
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
Welfare Benefit Premiums Paid to Carrier	USD $837,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,122
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0412866

Policy instance

Insurance contract or identification number	R0412866
Number of Individuals Covered	148
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $10,449
Total amount of fees paid to insurance company	USD $1,356
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	CRITICAL ILLNESS
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 $33,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,422
Amount paid for insurance broker fees	1159
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

097850

Policy instance

Insurance contract or identification number	097850
Number of Individuals Covered	873
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $2,723
Total amount of fees paid to insurance company	USD $583
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $27,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,723
Amount paid for insurance broker fees	583
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

9392136

Policy instance

Insurance contract or identification number	9392136
Number of Individuals Covered	324
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $46,926
Total amount of fees paid to insurance company	USD $5,279
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $73,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,004
Amount paid for insurance broker fees	4533
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	135
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $7,031
Total amount of fees paid to insurance company	USD $4,185
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
Welfare Benefit Premiums Paid to Carrier	USD $84,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,031
Amount paid for insurance broker fees	4185
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SVCS INC.

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

897389

Policy instance

Insurance contract or identification number	897389
Number of Individuals Covered	221
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $4,317
Total amount of fees paid to insurance company	USD $2,569
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
Welfare Benefit Premiums Paid to Carrier	USD $49,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,317
Amount paid for insurance broker fees	2569
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SVCS INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

097851

Policy instance

Insurance contract or identification number	097851
Number of Individuals Covered	102
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $9,183
Total amount of fees paid to insurance company	USD $1,182
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $54,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,183
Amount paid for insurance broker fees	1182
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SVCS INC.

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

473190

Policy instance

Insurance contract or identification number	473190
Number of Individuals Covered	627
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $83,073
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,769,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $83,073
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SVCS INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0412866

Policy instance

Insurance contract or identification number	R0412866
Number of Individuals Covered	102
Insurance policy start date	2016-04-01
Insurance policy end date	2017-03-31
Total amount of commissions paid to insurance broker	USD $702
Total amount of fees paid to insurance company	USD $16
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	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $702
Amount paid for insurance broker fees	16
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SVCS INC.

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

9392136

Policy instance

Insurance contract or identification number	9392136
Number of Individuals Covered	119
Insurance policy start date	2016-04-01
Insurance policy end date	2017-03-31
Total amount of commissions paid to insurance broker	USD $461
Total amount of fees paid to insurance company	USD $13
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	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,530
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $461
Amount paid for insurance broker fees	13
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SVCS INC.

SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

115/116/117

Policy instance

Insurance contract or identification number	115/116/117
Number of Individuals Covered	382
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $23,895
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
Welfare Benefit Premiums Paid to Carrier	USD $802,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,895
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SVCS INC.

NATIONAL HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 82538 )

Policy contract number

Y5688

Policy instance

Insurance contract or identification number	Y5688
Number of Individuals Covered	4
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $4,874
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 $162,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,874
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SVCS INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

097850

Policy instance

Insurance contract or identification number	097850
Number of Individuals Covered	354
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $2,995
Total amount of fees paid to insurance company	USD $560
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $26,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,995
Amount paid for insurance broker fees	560
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS SVCS INC.

Was this data useful?

If you found the data here useful, PLEASE HELP US. We are a start-up and believe in making information freely available. By linking to us, posting on twitter, facebook and linkedin about us and generally spreading the word, you'll help us to grow. Our vision is to provide high quality data about the activities of all the companies in the world and where possible make it free to use and view. Finding and integrating data from thousands of data sources is time consuming and needs lots of effort. By simply spreading the word about us, you will help us. Please use the share buttons. It will only take a few seconds of your time. Thanks for helping

Information Disclaimer

The information provided on this website is not advice, endorsement or recommendation
The information published is supplied by third parties so we make no warranty on the accuracy, completeness etc. This information is provided "as-is". The information is subject to change as we obtain updates and corrections from the primary information sources.
You are free to use the information for your own personal research on the understanding to do so is at your own risk.

See full terms and conditions

Company Name:	EVANS HOTELS, LLC
Employer identification number (EIN):	810750751
NAIC Classification:	721110
NAIC Description:	Hotels (except Casino Hotels) and Motels