401k Plan data: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN plan

AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN
Plan identification number	501

AVALON HEALTH CARE INC. EMPLOYEE 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) Prepaid legal Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

AVALON HEALTH CARE, INC. has sponsored the creation of one or more 401k plans.

Company Name: AVALON HEALTH CARE, INC.

Employer identification number (EIN): 870462037

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 RYAN D. NELSON 2023-06-09
501 2021-01-01 CAROLINE MCKENZIE 2022-07-26
501 2020-01-01 CAROLINE MCKENZIE 2021-07-13
501 2019-01-01 CAROLINE MCKENZIE 2020-08-10
501 2018-01-01
501 2017-01-01
501 2016-01-01 BYRON KIRTON BYRON KIRTON 2017-10-17
501 2016-01-01 BYRON KIRTON BYRON KIRTON 2018-01-04
501 2015-01-01 BYRON KIRTON
501 2014-01-01 BYRON KIRTON
501 2014-01-01 BYRON KIRTON
501 2013-01-01 DAVID SLAWSON
501 2012-01-01 DAVID SLAWSON
501 2011-01-01 DAVID SLAWSON
501 2009-01-01 DAVID SLAWSON

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	RYAN D. NELSON	2023-06-09
501	2021-01-01	CAROLINE MCKENZIE	2022-07-26
501	2020-01-01	CAROLINE MCKENZIE	2021-07-13
501	2019-01-01	CAROLINE MCKENZIE	2020-08-10
501	2018-01-01
501	2017-01-01
501	2016-01-01	BYRON KIRTON		BYRON KIRTON	2017-10-17
501	2016-01-01	BYRON KIRTON		BYRON KIRTON	2018-01-04
501	2015-01-01	BYRON KIRTON
501	2014-01-01	BYRON KIRTON
501	2014-01-01	BYRON KIRTON
501	2013-01-01	DAVID SLAWSON
501	2012-01-01	DAVID SLAWSON
501	2011-01-01	DAVID SLAWSON
501	2009-01-01	DAVID SLAWSON

Plan Statistics for AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 3,419
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 2,946
Number of retired or separated participants receiving benefits 2022-01-01 17
Number of other retired or separated participants entitled to future benefits 2022-01-01 117
Total of all active and inactive participants 2022-01-01 3,080
Number of employers contributing to the scheme 2022-01-01 0
2021: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 4,258
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 3,411
Number of retired or separated participants receiving benefits 2021-01-01 15
Number of other retired or separated participants entitled to future benefits 2021-01-01 994
Total of all active and inactive participants 2021-01-01 4,420
Number of employers contributing to the scheme 2021-01-01 0
2020: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 4,140
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 4,148
Number of retired or separated participants receiving benefits 2020-01-01 7
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 4,155
Number of employers contributing to the scheme 2020-01-01 0
2019: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 5,377
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 5,484
Number of retired or separated participants receiving benefits 2019-01-01 13
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 5,497
Number of employers contributing to the scheme 2019-01-01 0
2018: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 4,615
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 4,519
Number of retired or separated participants receiving benefits 2018-01-01 18
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 4,537
Number of employers contributing to the scheme 2018-01-01 0
2017: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 5,618
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 5,270
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 5,270
2016: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 4,248
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 4,343
Number of retired or separated participants receiving benefits 2016-01-01 4
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 4,347
2015: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 3,920
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 4,235
Number of retired or separated participants receiving benefits 2015-01-01 13
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 4,248
2014: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 3,658
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 3,916
Number of retired or separated participants receiving benefits 2014-01-01 4
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 3,920
2013: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 7,194
Total of all active and inactive participants 2013-01-01 7,194
Total participants 2013-01-01 7,194
Number of employers contributing to the scheme 2013-01-01 0
2012: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 7,244
Number of retired or separated participants receiving benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 7,244
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 7,244
Number of participants with account balances 2012-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
Number of employers contributing to the scheme 2012-01-01 0
2011: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 3,181
Number of retired or separated participants receiving benefits 2011-01-01 1
Total of all active and inactive participants 2011-01-01 3,182
Total participants 2011-01-01 3,182
2009: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 6,218
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 6,218
Total participants 2009-01-01 6,218

Measure	Date	Value
2022: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	3,419
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	2,946
Number of retired or separated participants receiving benefits	2022-01-01	17
Number of other retired or separated participants entitled to future benefits	2022-01-01	117
Total of all active and inactive participants	2022-01-01	3,080
Number of employers contributing to the scheme	2022-01-01	0
2021: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	4,258
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	3,411
Number of retired or separated participants receiving benefits	2021-01-01	15
Number of other retired or separated participants entitled to future benefits	2021-01-01	994
Total of all active and inactive participants	2021-01-01	4,420
Number of employers contributing to the scheme	2021-01-01	0
2020: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	4,140
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	4,148
Number of retired or separated participants receiving benefits	2020-01-01	7
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	4,155
Number of employers contributing to the scheme	2020-01-01	0
2019: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	5,377
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	5,484
Number of retired or separated participants receiving benefits	2019-01-01	13
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	5,497
Number of employers contributing to the scheme	2019-01-01	0
2018: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	4,615
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	4,519
Number of retired or separated participants receiving benefits	2018-01-01	18
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	4,537
Number of employers contributing to the scheme	2018-01-01	0
2017: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	5,618
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	5,270
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	5,270
2016: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	4,248
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	4,343
Number of retired or separated participants receiving benefits	2016-01-01	4
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	4,347
2015: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	3,920
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	4,235
Number of retired or separated participants receiving benefits	2015-01-01	13
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	4,248
2014: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	3,658
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	3,916
Number of retired or separated participants receiving benefits	2014-01-01	4
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	3,920
2013: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	7,194
Total of all active and inactive participants	2013-01-01	7,194
Total participants	2013-01-01	7,194
Number of employers contributing to the scheme	2013-01-01	0
2012: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	7,244
Number of retired or separated participants receiving benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	7,244
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	7,244
Number of participants with account balances	2012-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
Number of employers contributing to the scheme	2012-01-01	0
2011: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	3,181
Number of retired or separated participants receiving benefits	2011-01-01	1
Total of all active and inactive participants	2011-01-01	3,182
Total participants	2011-01-01	3,182
2009: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	6,218
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	6,218
Total participants	2009-01-01	6,218

Form 5500 Responses for AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN

2022: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	Yes
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: AVALON HEALTH CARE INC. EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30073339

Policy instance

Insurance contract or identification number	30073339
Number of Individuals Covered	1660
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $24,877
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $247,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,874
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1009280
Number of Individuals Covered	386
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,248
Total amount of fees paid to insurance company	USD $3,996
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $151,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,248
Amount paid for insurance broker fees	3996
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Health Insurance Welfare Benefit	Yes

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX969179

Policy instance

Insurance contract or identification number	FLX969179
Number of Individuals Covered	2946
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $60,837
Total amount of fees paid to insurance company	USD $16,071
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $636,643
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $62,197
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OVERRIDE

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

LBT

Policy instance

Insurance contract or identification number	LBT
Number of Individuals Covered	136
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $50,554
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $50,554
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

302033

Policy instance

Insurance contract or identification number	302033
Number of Individuals Covered	211
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,850
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $44,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,850
Amount paid for insurance broker fees	0
Insurance broker organization code?	4

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

Policy contract number

00000

Policy instance

Insurance contract or identification number	00000
Number of Individuals Covered	1715
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TELEHEALTH
Welfare Benefit Premiums Paid to Carrier	USD $66,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600482

Policy instance

Insurance contract or identification number	600482
Number of Individuals Covered	178
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $28,597
Total amount of fees paid to insurance company	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $910,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,597
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

229742

Policy instance

Insurance contract or identification number	229742
Number of Individuals Covered	1160
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $169,331
Total amount of fees paid to insurance company	USD $2,464
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	HOSPITAL,ACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $577,316
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $169,331
Amount paid for insurance broker fees	189
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1410
Number of Individuals Covered	113
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,801
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $762,360
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,801
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30073339

Policy instance

Insurance contract or identification number	30073339
Number of Individuals Covered	1852
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $28,510
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $279,473
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,510
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

LBT

Policy instance

Insurance contract or identification number	LBT
Number of Individuals Covered	109
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $67,628
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $67,628
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

00000

Policy instance

Insurance contract or identification number	00000
Number of Individuals Covered	1822
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TELEHEALTH
Welfare Benefit Premiums Paid to Carrier	USD $59,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

302033

Policy instance

Insurance contract or identification number	302033
Number of Individuals Covered	306
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $8,330
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $34,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,636
Amount paid for insurance broker fees	0
Insurance broker organization code?	4

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX969179

Policy instance

Insurance contract or identification number	FLX969179
Number of Individuals Covered	3411
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $74,436
Total amount of fees paid to insurance company	USD $6,274
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $831,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $74,472
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SERVICE FEES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600482

Policy instance

Insurance contract or identification number	600482
Number of Individuals Covered	199
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $33,351
Total amount of fees paid to insurance company	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $1,034,797
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,351
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

229742

Policy instance

Insurance contract or identification number	229742
Number of Individuals Covered	1368
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $372,702
Total amount of fees paid to insurance company	USD $7,351
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	HOSPITAL,ACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $735,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $372,702
Amount paid for insurance broker fees	162
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

68726-0

Policy instance

Insurance contract or identification number	68726-0
Number of Individuals Covered	1710
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $196,409
Total amount of fees paid to insurance company	USD $190,271
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $759,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $196,409
Amount paid for insurance broker fees	129507
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

6090928

Policy instance

Insurance contract or identification number	6090928
Number of Individuals Covered	165
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,695
Total amount of fees paid to insurance company	USD $593
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $42,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,695
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1410
Number of Individuals Covered	99
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $19,887
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $690,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,887
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600482

Policy instance

Insurance contract or identification number	600482
Number of Individuals Covered	217
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $34,624
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,170,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,624
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30073339

Policy instance

Insurance contract or identification number	30073339
Number of Individuals Covered	1952
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $25,557
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $299,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,557
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX969179

Policy instance

Insurance contract or identification number	FLX969179
Number of Individuals Covered	4148
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $65,183
Total amount of fees paid to insurance company	USD $71,116
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $698,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $65,183
Amount paid for insurance broker fees	71116
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

106063-001

Policy instance

Insurance contract or identification number	106063-001
Number of Individuals Covered	201
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $32,712
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,281,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	32712
Additional information about fees paid to insurance broker	CONSULTANT FEE
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1410
Number of Individuals Covered	82
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $20,671
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $567,605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,671
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

68726

Policy instance

Insurance contract or identification number	68726
Number of Individuals Covered	1797
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $315,546
Total amount of fees paid to insurance company	USD $85,329
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $890,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $315,546
Amount paid for insurance broker fees	38914
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

26620-1

Policy instance

Insurance contract or identification number	26620-1
Number of Individuals Covered	878
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,104,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600482

Policy instance

Insurance contract or identification number	600482
Number of Individuals Covered	222
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $32,819
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,118,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,819
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30073339

Policy instance

Insurance contract or identification number	30073339
Number of Individuals Covered	1423
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $18,844
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $229,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,844
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

907565

Policy instance

Insurance contract or identification number	907565
Number of Individuals Covered	4750
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $63,359
Total amount of fees paid to insurance company	USD $8,913
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $698,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63,311
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

6090928

Policy instance

Insurance contract or identification number	6090928
Number of Individuals Covered	156
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,816
Total amount of fees paid to insurance company	USD $503
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $28,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,773
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

68726

Policy instance

Insurance contract or identification number	68726
Number of Individuals Covered	1781
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $334,722
Total amount of fees paid to insurance company	USD $70,297
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $892,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $334,722
Amount paid for insurance broker fees	34601
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

6090928

Policy instance

Insurance contract or identification number	6090928
Number of Individuals Covered	168
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,902
Total amount of fees paid to insurance company	USD $503
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $38,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,902
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0307120-0231735

Policy instance

Insurance contract or identification number	0307120-0231735
Number of Individuals Covered	272
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $88
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $136,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	88
Additional information about fees paid to insurance broker	INDIRECT COMPENSATION
Insurance broker organization code?	3

REGENCE BLUECROSS BLUESHIELD OF UTAH (National Association of Insurance Commissioners NAIC id number: 54550 )

Policy contract number

10017256

Policy instance

Insurance contract or identification number	10017256
Number of Individuals Covered	288
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $62,714
Total amount of fees paid to insurance company	USD $10,485
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,921,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,714
Amount paid for insurance broker fees	10485
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1410
Number of Individuals Covered	128
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $26,749
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $791,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,749
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

26620-1

Policy instance

Insurance contract or identification number	26620-1
Number of Individuals Covered	1227
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,618,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600482

Policy instance

Insurance contract or identification number	600482
Number of Individuals Covered	231
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $31,913
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,094,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,913
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

907565

Policy instance

Insurance contract or identification number	907565
Number of Individuals Covered	3213
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $83,591
Total amount of fees paid to insurance company	USD $11,001
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $956,578
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $83,543
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

68726-0

Policy instance

Insurance contract or identification number	68726-0
Number of Individuals Covered	3282
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $559,506
Total amount of fees paid to insurance company	USD $76,836
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $1,967,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $501,358
Amount paid for insurance broker fees	44640
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

6090928

Policy instance

Insurance contract or identification number	6090928
Number of Individuals Covered	167
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,602
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $36,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,602
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BNEEFIT SERVICES, INC.

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0307120-0231735

Policy instance

Insurance contract or identification number	0307120-0231735
Number of Individuals Covered	730
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $87
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $348,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	87
Additional information about fees paid to insurance broker	INDIRECT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1410
Number of Individuals Covered	131
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12,549
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $695,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,549
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

REGENCE BLUECROSS BLUESHIELD OF UTAH (National Association of Insurance Commissioners NAIC id number: 54550 )

Policy contract number

10017256

Policy instance

Insurance contract or identification number	10017256
Number of Individuals Covered	636
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $98,128
Total amount of fees paid to insurance company	USD $4,590
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,313,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89,564
Amount paid for insurance broker fees	4590
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH AND BENEFITS, LLC.

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

26620-1

Policy instance

Insurance contract or identification number	26620-1
Number of Individuals Covered	3740
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,829,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600482

Policy instance

Insurance contract or identification number	600482
Number of Individuals Covered	285
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $30,182
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,268,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,961
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH AND BENEFITS, LLC

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

Policy contract number

907565

Policy instance

Insurance contract or identification number	907565
Number of Individuals Covered	3453
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $82,297
Total amount of fees paid to insurance company	USD $10,356
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $963,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82,249
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	MERCER HEALTH AND BENEFITS, LLC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1410
Number of Individuals Covered	116
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $505,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30052701

Policy instance

Insurance contract or identification number	30052701
Number of Individuals Covered	1374
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $15,884
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,884
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS, LLC

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

Policy contract number

907566

Policy instance

Insurance contract or identification number	907566
Number of Individuals Covered	1162
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $57,051
Total amount of fees paid to insurance company	USD $4,754
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE AND 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 $296,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $57,051
Amount paid for insurance broker fees	4754
Additional information about fees paid to insurance broker	ENHANCED COMMISSION COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

907565

Policy instance

Insurance contract or identification number	907565
Number of Individuals Covered	4662
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $16,172
Total amount of fees paid to insurance company	USD $3,963
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $277,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,172
Amount paid for insurance broker fees	3963
Additional information about fees paid to insurance broker	ENHANCED COMMISSION COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

6090928

Policy instance

Insurance contract or identification number	6090928
Number of Individuals Covered	69
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,303
Total amount of fees paid to insurance company	USD $96
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LEGAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,303
Amount paid for insurance broker fees	96
Additional information about fees paid to insurance broker	ENHANCED COMMISSION COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS, LLC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600482

Policy instance

Insurance contract or identification number	600482
Number of Individuals Covered	137
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $14,545
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $728,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,545
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS, LLC

KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )

Policy contract number

19855

Policy instance

Insurance contract or identification number	19855
Number of Individuals Covered	9
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $40,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FAMILY HEATH HAWAII (National Association of Insurance Commissioners NAIC id number: 15074 )

Policy contract number

1400004

Policy instance

Insurance contract or identification number	1400004
Number of Individuals Covered	80
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $327,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FAMILY HEATH HAWAII (National Association of Insurance Commissioners NAIC id number: 15074 )

Policy contract number

1400002

Policy instance

Insurance contract or identification number	1400002
Number of Individuals Covered	907
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,460,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

REGENCE BLUECROSS BLUESHIELD OF UTAH (National Association of Insurance Commissioners NAIC id number: 54550 )

Policy contract number

10017256

Policy instance

Insurance contract or identification number	10017256
Number of Individuals Covered	521
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $67,426
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,478,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67,426
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS, LLC

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

V7016

Policy instance

Insurance contract or identification number	V7016
Number of Individuals Covered	587
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $140,426
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT AND 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 $202,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $140,426
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS, LLC

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

92427

Policy instance

Insurance contract or identification number	92427
Number of Individuals Covered	272
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,537
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	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 $56,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,537
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS, LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0307120-0868918

Policy instance

Insurance contract or identification number	0307120-0868918
Number of Individuals Covered	519
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $209,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

907566

Policy instance

Insurance contract or identification number	907566
Number of Individuals Covered	1129
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $48,355
Total amount of fees paid to insurance company	USD $4,030
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE AND 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 $380,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,355
Amount paid for insurance broker fees	4030
Additional information about fees paid to insurance broker	ENHANCED COMMISSION COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

9136264

Policy instance

Insurance contract or identification number	9136264
Number of Individuals Covered	3916
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $766
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $766
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1410
Number of Individuals Covered	104
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $430,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

651941

Policy instance

Insurance contract or identification number	651941
Number of Individuals Covered	30
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,691
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $214,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,691
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

907565

Policy instance

Insurance contract or identification number	907565
Number of Individuals Covered	3916
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,609
Total amount of fees paid to insurance company	USD $1,787
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
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 $172,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,609
Amount paid for insurance broker fees	1787
Additional information about fees paid to insurance broker	ENHANCED COMMISSION COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

907565

Policy instance

Insurance contract or identification number	907565
Number of Individuals Covered	3582
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,495
Total amount of fees paid to insurance company	USD $1,627
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
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 $141,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,495
Amount paid for insurance broker fees	1627
Insurance broker name	MERCER HEALTH AND BENEFITS LLC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1410
Number of Individuals Covered	112
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $435,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011413

Policy instance

Insurance contract or identification number	30011413
Number of Individuals Covered	1289
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of fees paid to insurance company	USD $1,848,341
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $147,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

11062

Policy instance

Insurance contract or identification number	11062
Number of Individuals Covered	166
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	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 $611,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

11063

Policy instance

Insurance contract or identification number	11063
Number of Individuals Covered	2
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	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 $119,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

11067

Policy instance

Insurance contract or identification number	11067
Number of Individuals Covered	69
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	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 $298,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

11067-3

Policy instance

Insurance contract or identification number	11067-3
Number of Individuals Covered	1
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	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 $4,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

11068

Policy instance

Insurance contract or identification number	11068
Number of Individuals Covered	2
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	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 $10,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

95896

Policy instance

Insurance contract or identification number	95896
Number of Individuals Covered	16
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	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 $348,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

95898

Policy instance

Insurance contract or identification number	95898
Number of Individuals Covered	431
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	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 $1,481,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

95899

Policy instance

Insurance contract or identification number	95899
Number of Individuals Covered	7
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	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 $14,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )

Policy contract number

96259

Policy instance

Insurance contract or identification number	96259
Number of Individuals Covered	212
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	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 $628,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

651941

Policy instance

Insurance contract or identification number	651941
Number of Individuals Covered	44
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $10,716
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $201,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,431
Insurance broker name	MERCER HEALTH & BENEFITS, LLC

HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance contract or identification number	3
Number of Individuals Covered	134
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $49,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

907566

Policy instance

Insurance contract or identification number	907566
Number of Individuals Covered	1106
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $44,973
Total amount of fees paid to insurance company	USD $3,748
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
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 $352,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,973
Amount paid for insurance broker fees	3748
Insurance broker name	MERCER HEALTH & BENEFITS - SAL

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011413

Policy instance

Insurance contract or identification number	30011413
Number of Individuals Covered	1329
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600482

Policy instance

Insurance contract or identification number	600482
Number of Individuals Covered	28
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Welfare Benefit Premiums Paid to Carrier	USD $220,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1641

Policy instance

Insurance contract or identification number	1641
Number of Individuals Covered	133
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

96260

Policy instance

Insurance contract or identification number	96260
Number of Individuals Covered	0
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

96259

Policy instance

Insurance contract or identification number	96259
Number of Individuals Covered	201
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $681,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

95899

Policy instance

Insurance contract or identification number	95899
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

95898

Policy instance

Insurance contract or identification number	95898
Number of Individuals Covered	431
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,594,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

95897

Policy instance

Insurance contract or identification number	95897
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

95896

Policy instance

Insurance contract or identification number	95896
Number of Individuals Covered	113
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $361,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

11068

Policy instance

Insurance contract or identification number	11068
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

11067

Policy instance

Insurance contract or identification number	11067
Number of Individuals Covered	68
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $255,370
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

11063

Policy instance

Insurance contract or identification number	11063
Number of Individuals Covered	2
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

11062

Policy instance

Insurance contract or identification number	11062
Number of Individuals Covered	164
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $655,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

907565

Policy instance

Insurance contract or identification number	907565
Number of Individuals Covered	3434
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,233
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $117,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $7,233
Amount paid for insurance broker fees	1499
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	MERCER HEALTH & BENEFITS - SAL

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

Policy contract number

907566

Policy instance

Insurance contract or identification number	907566
Number of Individuals Covered	1045
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $42,460
Total amount of fees paid to insurance company	USD $3,797
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $283,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $42,460
Amount paid for insurance broker fees	3797
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker name	MERCER HEALTH & BENEFITS - SAL

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1410
Number of Individuals Covered	1008
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Welfare Benefit Premiums Paid to Carrier	USD $398,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

307120

Policy instance

Insurance contract or identification number	307120
Number of Individuals Covered	184
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,869
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $755,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,869
Insurance broker name	MERCER HEALTH & BENEFITS LLC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

Policy instance

Number of Individuals Covered	24
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $176,681

PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LTD. (National Association of Insurance Commissioners NAIC id number: 64343 )

Policy contract number

78151

Policy instance

Insurance contract or identification number	78151
Number of Individuals Covered	801
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $31,004
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $310,041

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

307120

Policy instance

Insurance contract or identification number	307120
Number of Individuals Covered	173
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $44,569
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $567,026

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011413

Policy instance

Insurance contract or identification number	30011413
Number of Individuals Covered	1170
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $122,518

HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1641

Policy instance

Insurance contract or identification number	1641
Number of Individuals Covered	117
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,365

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

Policy contract number

907566

Policy instance

Insurance contract or identification number	907566
Number of Individuals Covered	999
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $37,426
Health Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $246,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

11062

Policy instance

Insurance contract or identification number	11062
Number of Individuals Covered	591
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $4,212,473
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

Policy instance

Number of Individuals Covered	108
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $362,678

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

Policy instance

Number of Individuals Covered	41
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $290,264

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

307120

Policy instance

Insurance contract or identification number	307120
Number of Individuals Covered	3591
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $42,035
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $372,784

PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LTD. (National Association of Insurance Commissioners NAIC id number: 64343 )

Policy contract number

78151

Policy instance

Insurance contract or identification number	78151
Number of Individuals Covered	750
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $28,334
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $283,344

HAWAII DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1641

Policy instance

Insurance contract or identification number	1641
Number of Individuals Covered	106
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,984

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5249021

Policy instance

Insurance contract or identification number	5249021
Number of Individuals Covered	331
Insurance policy start date	2009-07-01
Insurance policy end date	2010-06-30
Total amount of commissions paid to insurance broker	USD $3,207
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,357

HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )

Policy contract number

227

Policy instance

Insurance contract or identification number	227
Number of Individuals Covered	547
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,325,412

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

1410

Policy instance

Insurance contract or identification number	1410
Number of Individuals Covered	125
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $317,778

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011413

Policy instance

Insurance contract or identification number	30011413
Number of Individuals Covered	897
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,740

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Company Name:	AVALON HEALTH CARE, INC.
Employer identification number (EIN):	870462037
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities