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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3344486 |
| Policy instance | 1 |
| Insurance contract or identification number | 3344486 | | Number of Individuals Covered | 1045 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 605823 0001 |
| Policy instance | 2 |
| Insurance contract or identification number | 605823 0001 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,176 | | Total amount of fees paid to insurance company | USD $967 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $48,344 | | 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: 00000 ) |
| Policy contract number | 606405 |
| Policy instance | 4 |
| Insurance contract or identification number | 606405 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $10,963 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $218,291 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WORKPLACE OPTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 7 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 1331 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $2,908 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 5953499 |
| Policy instance | 8 |
| Insurance contract or identification number | 5953499 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $3,197 | | Total amount of fees paid to insurance company | USD $33 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $21,399 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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