401k Plan data: EVISIONS INC plan

EVISIONS INC 401k Plan overview

Plan Name	EVISIONS INC
Plan identification number	501

EVISIONS INC Benefits

401k Plan Type

Welfare Benefit

Plan Features/Benefits

Health (other than dental or vision)
Life insurance
Dental
Vision
Temporary disability (accident and sickness)
Long-term disability cover
Death benefits (include travel accident but not life insurance)
Other welfare benefit cover
Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

EVISIONS, INC. has sponsored the creation of one or more 401k plans.

Company Name: EVISIONS, INC.

Employer identification number (EIN): 880411440

NAIC Classification: 541511
NAIC Description: Custom Computer Programming Services

Additional information about EVISIONS, INC.

Jurisdiction of Incorporation: Nevada Department of State

Incorporation Date: 1998-11-23

Company Identification Number: 19981385817

Legal Registered Office Address: 1489 W WARM SPRINGS BLVD STE 110-1F

HENDERSON
United States of America (USA)
89014

More information about EVISIONS, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EVISIONS INC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2017-01-01 SUSAN FIERRO SUSAN FIERRO 2018-06-27
501 2017-01-01
501 2016-01-01 SUSAN FIERRO

Plan Statistics for EVISIONS INC

401k plan membership statisitcs for EVISIONS INC

Measure Date Value
2021: EVISIONS INC 2021 401k membership
Total participants, beginning-of-year 2021-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 96
Number of retired or separated participants receiving benefits 2021-01-01 2
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 98
2020: EVISIONS INC 2020 401k membership
Total participants, beginning-of-year 2020-01-01 93
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 108
Number of retired or separated participants receiving benefits 2020-01-01 1
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 109
2019: EVISIONS INC 2019 401k membership
Total participants, beginning-of-year 2019-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 93
Number of retired or separated participants receiving benefits 2019-01-01 0
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 93
2017: EVISIONS INC 2017 401k membership
Total participants, beginning-of-year 2017-01-01 164
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 164
Number of retired or separated participants receiving benefits 2017-01-01 6
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 170
2016: EVISIONS INC 2016 401k membership
Total participants, beginning-of-year 2016-01-01 154
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 158
Number of retired or separated participants receiving benefits 2016-01-01 5
Number of other retired or separated participants entitled to future benefits 2016-01-01 1
Total of all active and inactive participants 2016-01-01 164

Measure	Date	Value
2021: EVISIONS INC 2021 401k membership
Total participants, beginning-of-year	2021-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	96
Number of retired or separated participants receiving benefits	2021-01-01	2
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	98
2020: EVISIONS INC 2020 401k membership
Total participants, beginning-of-year	2020-01-01	93
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	108
Number of retired or separated participants receiving benefits	2020-01-01	1
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	109
2019: EVISIONS INC 2019 401k membership
Total participants, beginning-of-year	2019-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	93
Number of retired or separated participants receiving benefits	2019-01-01	0
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	93
2017: EVISIONS INC 2017 401k membership
Total participants, beginning-of-year	2017-01-01	164
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	164
Number of retired or separated participants receiving benefits	2017-01-01	6
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	170
2016: EVISIONS INC 2016 401k membership
Total participants, beginning-of-year	2016-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	158
Number of retired or separated participants receiving benefits	2016-01-01	5
Number of other retired or separated participants entitled to future benefits	2016-01-01	1
Total of all active and inactive participants	2016-01-01	164

Form 5500 Responses for EVISIONS INC

2021: EVISIONS INC 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
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: EVISIONS INC 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
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: EVISIONS INC 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
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
2017: EVISIONS INC 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
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: EVISIONS INC 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	First time form 5500 has been submitted	Yes
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

652047

Policy instance

Insurance contract or identification number	652047
Number of Individuals Covered	96
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $961
Total amount of fees paid to insurance company	USD $168
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $9,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $961
Amount paid for insurance broker fees	168
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

652050

Policy instance

Insurance contract or identification number	652050
Number of Individuals Covered	89
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,170
Total amount of fees paid to insurance company	USD $205
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,170
Amount paid for insurance broker fees	205
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

652049

Policy instance

Insurance contract or identification number	652049
Number of Individuals Covered	30
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,888
Total amount of fees paid to insurance company	USD $330
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
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 $18,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,888
Amount paid for insurance broker fees	330
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

232480

Policy instance

Insurance contract or identification number	232480
Number of Individuals Covered	30
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,651
Total amount of fees paid to insurance company	USD $95
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $141,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,651
Amount paid for insurance broker fees	95
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001318

Policy instance

Insurance contract or identification number	W0001318
Number of Individuals Covered	67
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,031
Total amount of fees paid to insurance company	USD $30,603
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $807,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,031
Amount paid for insurance broker fees	30603
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES & BONUS OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

652048

Policy instance

Insurance contract or identification number	652048
Number of Individuals Covered	35
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,393
Total amount of fees paid to insurance company	USD $244
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $13,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,393
Amount paid for insurance broker fees	244
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

232480

Policy instance

Insurance contract or identification number	232480
Number of Individuals Covered	37
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,216
Total amount of fees paid to insurance company	USD $269
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $153,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,216
Amount paid for insurance broker fees	269
Additional information about fees paid to insurance broker	BONUS COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

652048

Policy instance

Insurance contract or identification number	652048
Number of Individuals Covered	42
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,472
Total amount of fees paid to insurance company	USD $589
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $14,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,472
Amount paid for insurance broker fees	589
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001318

Policy instance

Insurance contract or identification number	W0001318
Number of Individuals Covered	71
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,747
Total amount of fees paid to insurance company	USD $22,067
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	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 $593,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,747
Amount paid for insurance broker fees	22067
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES BONUS OVERRIDE COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

652047

Policy instance

Insurance contract or identification number	652047
Number of Individuals Covered	108
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,337
Total amount of fees paid to insurance company	USD $375
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $9,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,337
Amount paid for insurance broker fees	375
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

652049

Policy instance

Insurance contract or identification number	652049
Number of Individuals Covered	43
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,164
Total amount of fees paid to insurance company	USD $866
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
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 $21,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,164
Amount paid for insurance broker fees	866
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

232480

Policy instance

Insurance contract or identification number	232480
Number of Individuals Covered	41
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,848
Total amount of fees paid to insurance company	USD $180
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $162,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,848
Amount paid for insurance broker fees	180
Additional information about fees paid to insurance broker	BONUS COMMISSIONS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0B8SN

Policy instance

Insurance contract or identification number	GLUG0B8SN
Number of Individuals Covered	93
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $450
Total amount of fees paid to insurance company	USD $139
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $4,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $450
Amount paid for insurance broker fees	139
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B8SN

Policy instance

Insurance contract or identification number	GVTL0B8SN
Number of Individuals Covered	22
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,069
Total amount of fees paid to insurance company	USD $442
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $7,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,069
Amount paid for insurance broker fees	442
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPR0B8SN

Policy instance

Insurance contract or identification number	GUPR0B8SN
Number of Individuals Covered	25
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,441
Total amount of fees paid to insurance company	USD $297
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
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 $16,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,441
Amount paid for insurance broker fees	297
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

19965

Policy instance

Insurance contract or identification number	19965
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $387
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $387
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0B8SN

Policy instance

Insurance contract or identification number	GUDE0B8SN
Number of Individuals Covered	7
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $166
Total amount of fees paid to insurance company	USD $149
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $166
Amount paid for insurance broker fees	149
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0B8SN

Policy instance

Insurance contract or identification number	GUDH0B8SN
Number of Individuals Covered	5
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $228
Total amount of fees paid to insurance company	USD $170
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $228
Amount paid for insurance broker fees	170
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUC 0B8SN

Policy instance

Insurance contract or identification number	GUC 0B8SN
Number of Individuals Covered	20
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,314
Total amount of fees paid to insurance company	USD $190
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
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 $8,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,314
Amount paid for insurance broker fees	190
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001318

Policy instance

Insurance contract or identification number	W0001318
Number of Individuals Covered	57
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,183
Total amount of fees paid to insurance company	USD $19,278
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	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 $532,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,183
Amount paid for insurance broker fees	19278
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES BONUS OVERRIDE COMMISSIONS
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001318

Policy instance

Insurance contract or identification number	W0001318
Number of Individuals Covered	62
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $41,437
Total amount of fees paid to insurance company	USD $2,284
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	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 $849,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

30/5469322

Policy instance

Insurance contract or identification number	30/5469322
Number of Individuals Covered	14
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $778
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
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 $7,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

WJ359

Policy instance

Insurance contract or identification number	WJ359
Number of Individuals Covered	8
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,490
Total amount of fees paid to insurance company	USD $133
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY ACCIDENT, CRITICAL ILLNESS AND HOSPITAL INDEMNITY COVERAGE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,947
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

232480

Policy instance

Insurance contract or identification number	232480
Number of Individuals Covered	26
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,092
Total amount of fees paid to insurance company	USD $355
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $124,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )

Policy contract number

W0001318

Policy instance

Insurance contract or identification number	W0001318
Number of Individuals Covered	164
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $908
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $9,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $612
Insurance broker organization code?	3
Insurance broker name	BURNHAM BENEFITS INSURANCE SERVICES

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

Policy contract number

5469320

Policy instance

Insurance contract or identification number	5469320
Number of Individuals Covered	24
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $915
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $10,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $915
Insurance broker organization code?	3
Insurance broker name	WOODRUFF-SAWYER & CO.

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

WJ359

Policy instance

Insurance contract or identification number	WJ359
Number of Individuals Covered	8
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,490
Total amount of fees paid to insurance company	USD $133
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY ACCIDENT, CRITICAL ILLNESS AND HOSPITAL INDEMNITY COVERAGE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,490
Amount paid for insurance broker fees	133
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	VARIOUS - SEE ATTACHED

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

Policy contract number

30/5469322

Policy instance

Insurance contract or identification number	30/5469322
Number of Individuals Covered	14
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $778
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
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 $7,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $729
Insurance broker organization code?	3
Insurance broker name	BURNHAM BENEFITS INSURANCE SERVICES

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

Policy contract number

34/5469321

Policy instance

Insurance contract or identification number	34/5469321
Number of Individuals Covered	20
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,073
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,073
Insurance broker organization code?	3
Insurance broker name	WOODRUFF-SAWYER & CO.

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001318

Policy instance

Insurance contract or identification number	W0001318
Number of Individuals Covered	62
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $41,437
Total amount of fees paid to insurance company	USD $2,284
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	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 $849,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,033
Amount paid for insurance broker fees	2284
Additional information about fees paid to insurance broker	BONUS OVERRIDE COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	BURNHAM BENEFITS INSURANCE SERVICES

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

Policy contract number

232480

Policy instance

Insurance contract or identification number	232480
Number of Individuals Covered	26
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,092
Total amount of fees paid to insurance company	USD $355
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $124,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,965
Amount paid for insurance broker fees	351
Additional information about fees paid to insurance broker	BONUS COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	BURNHAM BENEFITS INSURANCE SERVICES

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

Policy contract number

34/5469321

Policy instance

Insurance contract or identification number	34/5469321
Number of Individuals Covered	20
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,073
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5469320

Policy instance

Insurance contract or identification number	5469320
Number of Individuals Covered	24
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $915
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $10,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

19965

Policy instance

Insurance contract or identification number	19965
Number of Individuals Covered	2
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,181
Total amount of fees paid to insurance company	USD $19
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $37,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )

Policy contract number

W0001318

Policy instance

Insurance contract or identification number	W0001318
Number of Individuals Covered	164
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $908
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $9,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

19965

Policy instance

Insurance contract or identification number	19965
Number of Individuals Covered	2
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,181
Total amount of fees paid to insurance company	USD $19
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $37,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,181
Amount paid for insurance broker fees	19
Additional information about fees paid to insurance broker	BONUS COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	WOODRUFF-SAWYER & CO.

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Company Name:	EVISIONS, INC.
Employer identification number (EIN):	880411440
NAIC Classification:	541511
NAIC Description:	Custom Computer Programming Services

Jurisdiction of Incorporation:	Nevada Department of State
Incorporation Date:	1998-11-23
Company Identification Number:	19981385817
Legal Registered Office Address:	1489 W WARM SPRINGS BLVD STE 110-1F HENDERSON United States of America (USA) 89014