401k Plan data: HOLLANDER HOSPITALITY INC. plan

HOLLANDER HOSPITALITY INC. 401k Plan overview

Plan Name	HOLLANDER HOSPITALITY INC.
Plan identification number	501

HOLLANDER HOSPITALITY 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 Other welfare benefit cover

401k Sponsoring company profile

HOLLANDER HOSPITALITY, LLC has sponsored the creation of one or more 401k plans.

Company Name: HOLLANDER HOSPITALITY, LLC

Employer identification number (EIN): 911746890

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

Additional information about HOLLANDER HOSPITALITY, LLC

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division

Incorporation Date: 1996-12-20

Company Identification Number: 601758030

Legal Registered Office Address: 119 N COMMERCIAL ST STE 165

BELLINGHAM
United States of America (USA)
982254452

More information about HOLLANDER HOSPITALITY, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOLLANDER HOSPITALITY INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 JASON KOOI 2023-05-30 JASON KOOI 2023-05-30
501 2021-01-01 JASON KOOI 2022-05-19 JASON KOOI 2022-05-19
501 2020-01-01 JASON KOOI 2021-07-13
501 2019-01-01 JASON KOONI 2020-04-27
501 2018-01-01 JASON KOONI 2019-06-12
501 2017-01-01
501 2016-01-01
501 2015-03-01
501 2014-03-01
501 2013-03-01
501 2012-03-01 BARBARA THOMPSON
501 2011-03-01 BARBARA THOMPSON
501 2009-03-01 BARBARA THOMPSON

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	JASON KOOI	2023-05-30	JASON KOOI	2023-05-30
501	2021-01-01	JASON KOOI	2022-05-19	JASON KOOI	2022-05-19
501	2020-01-01	JASON KOOI	2021-07-13
501	2019-01-01	JASON KOONI	2020-04-27
501	2018-01-01	JASON KOONI	2019-06-12
501	2017-01-01
501	2016-01-01
501	2015-03-01
501	2014-03-01
501	2013-03-01
501	2012-03-01	BARBARA THOMPSON
501	2011-03-01	BARBARA THOMPSON
501	2009-03-01	BARBARA THOMPSON

Plan Statistics for HOLLANDER HOSPITALITY INC.

401k plan membership statisitcs for HOLLANDER HOSPITALITY INC.

Measure Date Value
2022: HOLLANDER HOSPITALITY INC. 2022 401k membership
Total participants, beginning-of-year 2022-01-01 290
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 279
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 279
2021: HOLLANDER HOSPITALITY INC. 2021 401k membership
Total participants, beginning-of-year 2021-01-01 421
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 290
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 290
2020: HOLLANDER HOSPITALITY INC. 2020 401k membership
Total participants, beginning-of-year 2020-01-01 573
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 421
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 421
2019: HOLLANDER HOSPITALITY INC. 2019 401k membership
Total participants, beginning-of-year 2019-01-01 510
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 573
Total of all active and inactive participants 2019-01-01 573
2018: HOLLANDER HOSPITALITY INC. 2018 401k membership
Total participants, beginning-of-year 2018-01-01 428
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 510
Total of all active and inactive participants 2018-01-01 510
2017: HOLLANDER HOSPITALITY INC. 2017 401k membership
Total participants, beginning-of-year 2017-01-01 455
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 428
Total of all active and inactive participants 2017-01-01 428
2016: HOLLANDER HOSPITALITY INC. 2016 401k membership
Total participants, beginning-of-year 2016-01-01 456
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 455
Total of all active and inactive participants 2016-01-01 455
2015: HOLLANDER HOSPITALITY INC. 2015 401k membership
Total participants, beginning-of-year 2015-03-01 452
Total number of active participants reported on line 7a of the Form 5500 2015-03-01 456
Total of all active and inactive participants 2015-03-01 456
2014: HOLLANDER HOSPITALITY INC. 2014 401k membership
Total participants, beginning-of-year 2014-03-01 435
Total number of active participants reported on line 7a of the Form 5500 2014-03-01 452
Total of all active and inactive participants 2014-03-01 452
2013: HOLLANDER HOSPITALITY INC. 2013 401k membership
Total participants, beginning-of-year 2013-03-01 467
Total number of active participants reported on line 7a of the Form 5500 2013-03-01 435
Total of all active and inactive participants 2013-03-01 435
2012: HOLLANDER HOSPITALITY INC. 2012 401k membership
Total participants, beginning-of-year 2012-03-01 411
Total number of active participants reported on line 7a of the Form 5500 2012-03-01 467
Total of all active and inactive participants 2012-03-01 467
2011: HOLLANDER HOSPITALITY INC. 2011 401k membership
Total participants, beginning-of-year 2011-03-01 389
Total number of active participants reported on line 7a of the Form 5500 2011-03-01 410
Number of retired or separated participants receiving benefits 2011-03-01 1
Total of all active and inactive participants 2011-03-01 411
2009: HOLLANDER HOSPITALITY INC. 2009 401k membership
Total participants, beginning-of-year 2009-03-01 249
Total number of active participants reported on line 7a of the Form 5500 2009-03-01 242
Number of retired or separated participants receiving benefits 2009-03-01 0
Number of other retired or separated participants entitled to future benefits 2009-03-01 0
Total of all active and inactive participants 2009-03-01 242
Total participants 2009-03-01 242

Measure	Date	Value
2022: HOLLANDER HOSPITALITY INC. 2022 401k membership
Total participants, beginning-of-year	2022-01-01	290
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	279
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	279
2021: HOLLANDER HOSPITALITY INC. 2021 401k membership
Total participants, beginning-of-year	2021-01-01	421
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	290
Number of retired or separated participants receiving benefits	2021-01-01	0
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	290
2020: HOLLANDER HOSPITALITY INC. 2020 401k membership
Total participants, beginning-of-year	2020-01-01	573
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	421
Number of retired or separated participants receiving benefits	2020-01-01	0
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	421
2019: HOLLANDER HOSPITALITY INC. 2019 401k membership
Total participants, beginning-of-year	2019-01-01	510
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	573
Total of all active and inactive participants	2019-01-01	573
2018: HOLLANDER HOSPITALITY INC. 2018 401k membership
Total participants, beginning-of-year	2018-01-01	428
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	510
Total of all active and inactive participants	2018-01-01	510
2017: HOLLANDER HOSPITALITY INC. 2017 401k membership
Total participants, beginning-of-year	2017-01-01	455
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	428
Total of all active and inactive participants	2017-01-01	428
2016: HOLLANDER HOSPITALITY INC. 2016 401k membership
Total participants, beginning-of-year	2016-01-01	456
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	455
Total of all active and inactive participants	2016-01-01	455
2015: HOLLANDER HOSPITALITY INC. 2015 401k membership
Total participants, beginning-of-year	2015-03-01	452
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	456
Total of all active and inactive participants	2015-03-01	456
2014: HOLLANDER HOSPITALITY INC. 2014 401k membership
Total participants, beginning-of-year	2014-03-01	435
Total number of active participants reported on line 7a of the Form 5500	2014-03-01	452
Total of all active and inactive participants	2014-03-01	452
2013: HOLLANDER HOSPITALITY INC. 2013 401k membership
Total participants, beginning-of-year	2013-03-01	467
Total number of active participants reported on line 7a of the Form 5500	2013-03-01	435
Total of all active and inactive participants	2013-03-01	435
2012: HOLLANDER HOSPITALITY INC. 2012 401k membership
Total participants, beginning-of-year	2012-03-01	411
Total number of active participants reported on line 7a of the Form 5500	2012-03-01	467
Total of all active and inactive participants	2012-03-01	467
2011: HOLLANDER HOSPITALITY INC. 2011 401k membership
Total participants, beginning-of-year	2011-03-01	389
Total number of active participants reported on line 7a of the Form 5500	2011-03-01	410
Number of retired or separated participants receiving benefits	2011-03-01	1
Total of all active and inactive participants	2011-03-01	411
2009: HOLLANDER HOSPITALITY INC. 2009 401k membership
Total participants, beginning-of-year	2009-03-01	249
Total number of active participants reported on line 7a of the Form 5500	2009-03-01	242
Number of retired or separated participants receiving benefits	2009-03-01	0
Number of other retired or separated participants entitled to future benefits	2009-03-01	0
Total of all active and inactive participants	2009-03-01	242
Total participants	2009-03-01	242

Form 5500 Responses for HOLLANDER HOSPITALITY INC.

2022: HOLLANDER HOSPITALITY INC. 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: HOLLANDER HOSPITALITY 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 – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: HOLLANDER HOSPITALITY INC. 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 benefit arrangement – Insurance	Yes
2019: HOLLANDER HOSPITALITY INC. 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 benefit arrangement – Insurance	Yes
2018: HOLLANDER HOSPITALITY INC. 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 benefit arrangement – Insurance	Yes
2017: HOLLANDER HOSPITALITY INC. 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 benefit arrangement – Insurance	Yes
2016: HOLLANDER HOSPITALITY INC. 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: HOLLANDER HOSPITALITY INC. 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2014: HOLLANDER HOSPITALITY INC. 2014 form 5500 responses
2014-03-01	Type of plan entity	Single employer plan
2014-03-01	Plan funding arrangement – Insurance	Yes
2014-03-01	Plan benefit arrangement – Insurance	Yes
2013: HOLLANDER HOSPITALITY INC. 2013 form 5500 responses
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes
2012: HOLLANDER HOSPITALITY INC. 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	Plan funding arrangement – Insurance	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes
2011: HOLLANDER HOSPITALITY INC. 2011 form 5500 responses
2011-03-01	Type of plan entity	Single employer plan
2011-03-01	Plan funding arrangement – Insurance	Yes
2011-03-01	Plan benefit arrangement – Insurance	Yes
2009: HOLLANDER HOSPITALITY INC. 2009 form 5500 responses
2009-03-01	Type of plan entity	Single employer plan
2009-03-01	Submission has been amended	No
2009-03-01	This submission is the final filing	No
2009-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-03-01	Plan is a collectively bargained plan	No
2009-03-01	Plan funding arrangement – Insurance	Yes
2009-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

16116

Policy instance

Insurance contract or identification number	16116
Number of Individuals Covered	30
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,849
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 $178,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,849
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSION
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	10
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,961
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 $98,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,961
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1414600

Policy instance

Insurance contract or identification number	1414600
Number of Individuals Covered	143
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $19,882
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 $641,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,882
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4098984

Policy instance

Insurance contract or identification number	E4098984
Number of Individuals Covered	25
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,058
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	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 $29,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,516
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

923171

Policy instance

Insurance contract or identification number	923171
Number of Individuals Covered	279
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,181
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE AD&D
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 $14,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,181
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSION
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4098984

Policy instance

Insurance contract or identification number	E4098984
Number of Individuals Covered	29
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,367
Total amount of fees paid to insurance company	USD $184
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	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 $32,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,271
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

923171

Policy instance

Insurance contract or identification number	923171
Number of Individuals Covered	290
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $845
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 $6,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $544
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1414600

Policy instance

Insurance contract or identification number	1414600
Number of Individuals Covered	123
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $12,390
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 $453,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,390
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	19
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,264
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 $135,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,264
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

16116

Policy instance

Insurance contract or identification number	16116
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 $3,608
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 $113,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,608
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

923171

Policy instance

Insurance contract or identification number	923171
Number of Individuals Covered	290
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,904
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $20,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,904
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4098984

Policy instance

Insurance contract or identification number	E4098984
Number of Individuals Covered	40
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $15,695
Total amount of fees paid to insurance company	USD $6,445
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 $56,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,608
Insurance broker organization code?	3
Amount paid for insurance broker fees	2425

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1414600

Policy instance

Insurance contract or identification number	1414600
Number of Individuals Covered	162
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $21,842
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $787,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,842
Insurance broker organization code?	3

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

Policy contract number

16116

Policy instance

Insurance contract or identification number	16116
Number of Individuals Covered	47
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,925
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $329,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,925
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	26
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,274
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $188,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,274
Insurance broker organization code?	3

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

Policy contract number

16116

Policy instance

Insurance contract or identification number	16116
Number of Individuals Covered	65
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,675
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $381,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,675
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	36
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,584
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $213,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,584
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

923171

Policy instance

Insurance contract or identification number	923171
Number of Individuals Covered	418
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,095
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,095
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4098984

Policy instance

Insurance contract or identification number	E4098984
Number of Individuals Covered	37
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $12,171
Total amount of fees paid to insurance company	USD $6,433
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 $39,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,867
Amount paid for insurance broker fees	3411
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1414600

Policy instance

Insurance contract or identification number	1414600
Number of Individuals Covered	221
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $24,955
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $834,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,955
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306600

Policy instance

Insurance contract or identification number	6306600
Number of Individuals Covered	182
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $19,845
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $660,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,845
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1414600

Policy instance

Insurance contract or identification number	1414600
Number of Individuals Covered	6
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $685
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $685
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	40
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,204
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $213,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,204
Insurance broker organization code?	3

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

Policy contract number

KMO5989370

Policy instance

Insurance contract or identification number	KMO5989370
Number of Individuals Covered	510
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,825
Total amount of fees paid to insurance company	USD $13
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $172,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,825
Amount paid for insurance broker fees	13
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4098984

Policy instance

Insurance contract or identification number	E4098984
Number of Individuals Covered	29
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,503
Total amount of fees paid to insurance company	USD $2,009
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 $23,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,795
Amount paid for insurance broker fees	1821
Insurance broker organization code?	3

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

Policy contract number

16116

Policy instance

Insurance contract or identification number	16116
Number of Individuals Covered	66
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,557
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $343,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,557
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	29
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,401
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $149,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,401
Insurance broker organization code?	3
Insurance broker name	FORTIPHI LLC

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

Policy contract number

KMO5989370

Policy instance

Insurance contract or identification number	KMO5989370
Number of Individuals Covered	428
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,942
Total amount of fees paid to insurance company	USD $17
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $139,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,942
Amount paid for insurance broker fees	17
Insurance broker organization code?	3
Insurance broker name	FORTIPHI LLC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306600

Policy instance

Insurance contract or identification number	6306600
Number of Individuals Covered	145
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $16,853
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $562,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,853
Insurance broker organization code?	3
Insurance broker name	FORTIPHI LLC

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

Policy contract number

16116

Policy instance

Insurance contract or identification number	16116
Number of Individuals Covered	53
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,469
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $273,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,469
Insurance broker organization code?	3
Insurance broker name	FORTIPHI LLC

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1414600

Policy instance

Insurance contract or identification number	1414600
Number of Individuals Covered	12
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $912
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $912
Insurance broker organization code?	3
Insurance broker name	FORTIPHI LLC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4098984

Policy instance

Insurance contract or identification number	E4098984
Number of Individuals Covered	33
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,195
Total amount of fees paid to insurance company	USD $293
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 $20,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,489
Insurance broker organization code?	3
Amount paid for insurance broker fees	15
Insurance broker name	JULIE WOLDEN

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	31
Insurance policy start date	2015-03-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,983
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $125,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,983
Insurance broker organization code?	3
Insurance broker name	FORTIPHI LLC

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1414600

Policy instance

Insurance contract or identification number	1414600
Number of Individuals Covered	4
Insurance policy start date	2015-03-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $352
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $352
Insurance broker organization code?	3
Insurance broker name	FORTIPHI LLC

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

Policy contract number

5989370

Policy instance

Insurance contract or identification number	5989370
Number of Individuals Covered	358
Insurance policy start date	2015-03-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,370
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $99,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,370
Insurance broker organization code?	3
Insurance broker name	FORTIPHI LLC

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

Policy contract number

16116

Policy instance

Insurance contract or identification number	16116
Number of Individuals Covered	54
Insurance policy start date	2015-03-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,036
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $250,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,036
Insurance broker organization code?	3
Insurance broker name	FORTIPHI LLC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306600

Policy instance

Insurance contract or identification number	6306600
Number of Individuals Covered	121
Insurance policy start date	2015-03-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,392
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $342,937
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,392
Insurance broker organization code?	3
Insurance broker name	FORTIPHI LLC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4098984

Policy instance

Insurance contract or identification number	E4098984
Number of Individuals Covered	41
Insurance policy start date	2015-03-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,819
Total amount of fees paid to insurance company	USD $657
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 $23,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,686
Insurance broker organization code?	3
Amount paid for insurance broker fees	37
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	BENEFITS BY DESIGN INC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	29
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $3,166
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $165,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,166
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306600

Policy instance

Insurance contract or identification number	6306600
Number of Individuals Covered	117
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $11,566
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $448,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,566
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

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

Policy contract number

16116

Policy instance

Insurance contract or identification number	16116
Number of Individuals Covered	51
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $5,218
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $257,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,218
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

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

Policy contract number

KM05989370

Policy instance

Insurance contract or identification number	KM05989370
Number of Individuals Covered	442
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $5,135
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $131,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,135
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1414600

Policy instance

Insurance contract or identification number	1414600
Number of Individuals Covered	7
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $849
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $849
Insurance broker name

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4098984

Policy instance

Insurance contract or identification number	E4098984
Number of Individuals Covered	29
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $7,035
Total amount of fees paid to insurance company	USD $1,040
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	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 $23,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,035
Amount paid for insurance broker fees	1040
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4098984

Policy instance

Insurance contract or identification number	E4098984
Number of Individuals Covered	37
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $4,260
Total amount of fees paid to insurance company	USD $864
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	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 $9,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,260
Amount paid for insurance broker fees	864
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATIONSUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1414600

Policy instance

Insurance contract or identification number	1414600
Number of Individuals Covered	4
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $438
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $438
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

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

Policy contract number

16116

Policy instance

Insurance contract or identification number	16116
Number of Individuals Covered	46
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $5,123
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $202,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,123
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306600

Policy instance

Insurance contract or identification number	6306600
Number of Individuals Covered	129
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $15,693
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $561,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,693
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	23
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $3,483
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $170,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,483
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

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

Policy contract number

KM05989370

Policy instance

Insurance contract or identification number	KM05989370
Number of Individuals Covered	488
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $5,347
Total amount of fees paid to insurance company	USD $963
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $146,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,347
Amount paid for insurance broker fees	963
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

649623

Policy instance

Insurance contract or identification number	649623
Number of Individuals Covered	174
Insurance policy start date	2012-03-01
Insurance policy end date	2012-04-30
Total amount of commissions paid to insurance broker	USD $925
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $925
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

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

Policy contract number

KM05989370

Policy instance

Insurance contract or identification number	KM05989370
Number of Individuals Covered	434
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $4,157
Total amount of fees paid to insurance company	USD $324
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $95,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,157
Amount paid for insurance broker fees	324
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

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

Policy contract number

16116

Policy instance

Insurance contract or identification number	16116
Number of Individuals Covered	42
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $4,743
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $201,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,743
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306600

Policy instance

Insurance contract or identification number	6306600
Number of Individuals Covered	126
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $13,348
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $436,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,348
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	7
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $809
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $809
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	6
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $734
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

5403300

Policy instance

Insurance contract or identification number	5403300
Number of Individuals Covered	23
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $5,489
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $109,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1006439

Policy instance

Insurance contract or identification number	1006439
Number of Individuals Covered	275
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $4,647
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,702
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

Policy instance

Number of Individuals Covered	43
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $4,712
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $185,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306600

Policy instance

Insurance contract or identification number	6306600
Number of Individuals Covered	89
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $7,937
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $289,779
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

16116

Policy instance

Insurance contract or identification number	16116
Number of Individuals Covered	51
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $9,100
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $220,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,100
Insurance broker organization code?	3
Insurance broker name	BALDWIN RESOURCES GROUP INC.

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

5493300

Policy instance

Insurance contract or identification number	5493300
Number of Individuals Covered	26
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $2,458
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,458
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS PLANNING LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1006439

Policy instance

Insurance contract or identification number	1006439
Number of Individuals Covered	222
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $7,056
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $560
Insurance broker organization code?	3
Insurance broker name	BALDWIN RESOURCES GROUP INC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306600

Policy instance

Insurance contract or identification number	6306600
Number of Individuals Covered	81
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $10,342
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $306,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $796
Insurance broker organization code?	3
Insurance broker name	BALDWIN RESOURCES GROUP INC

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6306700

Policy instance

Insurance contract or identification number	6306700
Number of Individuals Covered	9
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $2,228
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $172
Insurance broker organization code?	3
Insurance broker name	BALDWIN RESOUCES GROUP INC

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Company Name:	HOLLANDER HOSPITALITY, LLC
Employer identification number (EIN):	911746890
NAIC Classification:	721110
NAIC Description:	Hotels (except Casino Hotels) and Motels

Jurisdiction of Incorporation:	Washington Secretary of State Corporations Division
Incorporation Date:	1996-12-20
Company Identification Number:	601758030
Legal Registered Office Address:	119 N COMMERCIAL ST STE 165 BELLINGHAM United States of America (USA) 982254452