FUJIMI CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan FUJIMI CORPORATION WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-10-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-10-01 | 132 |
| Number of retired or separated participants receiving benefits | 2022-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-10-01 | 0 |
| Total of all active and inactive participants | 2022-10-01 | 132 |
| Number of employers contributing to the scheme | 2022-10-01 | 0 |
| 2021: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 117 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 121 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 121 |
| Number of employers contributing to the scheme | 2021-10-01 | 0 |
| 2020: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 117 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 117 |
| Number of employers contributing to the scheme | 2020-10-01 | 0 |
| 2019: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 113 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 113 |
| Number of employers contributing to the scheme | 2019-10-01 | 0 |
| 2018: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 112 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 112 |
| Number of employers contributing to the scheme | 2018-10-01 | 0 |
| 2017: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 106 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 109 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 109 |
| Number of employers contributing to the scheme | 2017-10-01 | 0 |
| 2016: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 107 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 106 |
| Number of retired or separated participants receiving benefits | 2016-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
| Total of all active and inactive participants | 2016-10-01 | 106 |
| 2015: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 106 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 107 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
| Total of all active and inactive participants | 2015-10-01 | 107 |
| 2014: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 103 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 106 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-10-01 | 0 |
| Total of all active and inactive participants | 2014-10-01 | 106 |
| 2013: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 103 |
| Number of retired or separated participants receiving benefits | 2013-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-10-01 | 0 |
| Total of all active and inactive participants | 2013-10-01 | 103 |
| 2012: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-10-01 | 108 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 105 |
| Number of retired or separated participants receiving benefits | 2012-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-10-01 | 0 |
| Total of all active and inactive participants | 2012-10-01 | 105 |
| 2011: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 108 |
| Number of retired or separated participants receiving benefits | 2011-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-10-01 | 0 |
| Total of all active and inactive participants | 2011-10-01 | 108 |
| 2022: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-10-01 | Type of plan entity | Single employer plan |
| 2022-10-01 | Plan funding arrangement – Insurance | Yes |
| 2022-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Submission has been amended | No |
| 2015-10-01 | This submission is the final filing | No |
| 2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-10-01 | Plan is a collectively bargained plan | No |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Submission has been amended | No |
| 2014-10-01 | This submission is the final filing | No |
| 2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-10-01 | Plan is a collectively bargained plan | No |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | Submission has been amended | No |
| 2013-10-01 | This submission is the final filing | No |
| 2013-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-10-01 | Plan is a collectively bargained plan | No |
| 2013-10-01 | Plan funding arrangement – Insurance | Yes |
| 2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-10-01 | Type of plan entity | Single employer plan |
| 2012-10-01 | Submission has been amended | No |
| 2012-10-01 | This submission is the final filing | No |
| 2012-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-10-01 | Plan is a collectively bargained plan | No |
| 2012-10-01 | Plan funding arrangement – Insurance | Yes |
| 2012-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: FUJIMI CORPORATION WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Submission has been amended | No |
| 2011-10-01 | This submission is the final filing | No |
| 2011-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-10-01 | Plan is a collectively bargained plan | No |
| 2011-10-01 | Plan funding arrangement – Insurance | Yes |
| 2011-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 70800 |
| Policy instance | 4 |
| Insurance contract or identification number | 70800 | | Number of Individuals Covered | 132 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $10,681 | | Total amount of fees paid to insurance company | USD $25 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $80,558 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,681 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
|
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | V4775A ET AL |
| Policy instance | 3 |
| Insurance contract or identification number | V4775A ET AL | | Number of Individuals Covered | 82 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $52,878 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,762,603 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52,878 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 2 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 274 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $4,399 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $146,785 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,399 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 6572 |
| Policy instance | 1 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $17,236 | | Total amount of fees paid to insurance company | USD $339 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $527,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,236 | | Amount paid for insurance broker fees | 339 | | Additional information about fees paid to insurance broker | RETENTION BONUS | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 6572 |
| Policy instance | 1 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $16,421 | | Total amount of fees paid to insurance company | USD $337 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $554,973 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,421 | | Amount paid for insurance broker fees | 337 | | Additional information about fees paid to insurance broker | RETENTION BONUS, NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 2 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $4,386 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $146,194 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,386 | | Insurance broker organization code? | 3 |
|
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | V4775A ET AL |
| Policy instance | 3 |
| Insurance contract or identification number | V4775A ET AL | | Number of Individuals Covered | 79 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $48,136 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,604,532 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,136 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 70800 |
| Policy instance | 4 |
| Insurance contract or identification number | 70800 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $11,132 | | Total amount of fees paid to insurance company | USD $17 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $77,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,132 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 542414 |
| Policy instance | 4 |
| Insurance contract or identification number | 542414 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $8,673 | | Total amount of fees paid to insurance company | USD $2,573 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $78,879 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,673 | | Amount paid for insurance broker fees | 2573 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | V4775A ET AL |
| Policy instance | 3 |
| Insurance contract or identification number | V4775A ET AL | | Number of Individuals Covered | 82 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $46,486 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,549,543 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,486 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 2 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $4,594 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $139,575 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,594 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 6572 |
| Policy instance | 1 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 69 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $12,773 | | Total amount of fees paid to insurance company | USD $437 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $436,026 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,773 | | Amount paid for insurance broker fees | 437 | | Additional information about fees paid to insurance broker | RETENTION BONUS BONUS | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 6572 |
| Policy instance | 1 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $11,556 | | Total amount of fees paid to insurance company | USD $269 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $360,979 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,556 | | Amount paid for insurance broker fees | 269 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 2 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $4,670 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $142,381 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,670 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | V4775A ET AL |
| Policy instance | 3 |
| Insurance contract or identification number | V4775A ET AL | | Number of Individuals Covered | 81 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $42,265 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,537,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,265 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 542414 |
| Policy instance | 4 |
| Insurance contract or identification number | 542414 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $8,894 | | Total amount of fees paid to insurance company | USD $4,161 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $78,755 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,894 | | Amount paid for insurance broker fees | 4161 | | 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 | 6572 |
| Policy instance | 1 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $7,460 | | Total amount of fees paid to insurance company | USD $18 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $301,766 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,460 | | Amount paid for insurance broker fees | 18 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 2 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 273 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $4,456 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $133,846 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,456 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | V4775A ET AL |
| Policy instance | 3 |
| Insurance contract or identification number | V4775A ET AL | | Number of Individuals Covered | 85 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $42,476 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,415,863 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,476 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 542414 |
| Policy instance | 4 |
| Insurance contract or identification number | 542414 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $7,536 | | Total amount of fees paid to insurance company | USD $1,720 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $65,017 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,834 | | Amount paid for insurance broker fees | 1720 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 542414 |
| Policy instance | 4 |
| Insurance contract or identification number | 542414 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $7,568 | | Total amount of fees paid to insurance company | USD $734 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $64,583 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | V4775A ET AL |
| Policy instance | 3 |
| Insurance contract or identification number | V4775A ET AL | | Number of Individuals Covered | 90 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $38,387 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,391,777 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 2 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $4,347 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $129,484 | | 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 | 6572 |
| Policy instance | 1 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $6,639 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $189,139 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | WBT000922 |
| Policy instance | 5 |
| Insurance contract or identification number | WBT000922 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $7,046 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | 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 $59,737 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,938 | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 3 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $2,078 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,584 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,078 | | Insurance broker organization code? | 3 | | Insurance broker name | KIBBLE AND PRENTICE HOLDING COMPANY |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | 00 |
| Policy instance | 4 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $1,996 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $58,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,996 | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 6572 |
| Policy instance | 2 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $6,211 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $226,997 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,193 | | Insurance broker organization code? | 3 | | Insurance broker name | KIBBLE AND PRENTICE HOLDING COMPANY |
|
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | V4775B ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | V4775B ET AL | | Number of Individuals Covered | 87 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $33,691 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $1,123,020 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,213 | | Insurance broker organization code? | 3 | | Insurance broker name | KIBBLE AND PRENTICE HOLDING COMPANY |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 3 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $66,186 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | V4775B ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | V4775B ET AL | | Number of Individuals Covered | 83 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $31,214 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $1,040,453 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,214 | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 6572 |
| Policy instance | 2 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $5,459 | | Total amount of fees paid to insurance company | USD $234 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $197,500 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,459 | | Amount paid for insurance broker fees | 234 | | Additional information about fees paid to insurance broker | RETENTION BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | 00 |
| Policy instance | 4 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $46,758 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | WBT000922 |
| Policy instance | 5 |
| Insurance contract or identification number | WBT000922 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $6,786 | | Total amount of fees paid to insurance company | USD $2,079 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | 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 $57,447 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,786 | | Amount paid for insurance broker fees | 2079 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 6572 |
| Policy instance | 2 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $7,390 | | Total amount of fees paid to insurance company | USD $263 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $190,759 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,390 | | Amount paid for insurance broker fees | 263 | | Additional information about fees paid to insurance broker | RETENTION BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | V4775B ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | V4775B ET AL | | Number of Individuals Covered | 83 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $29,044 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $968,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,044 | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 3 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $3,772 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $106,494 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,772 | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | WBT000922 |
| Policy instance | 4 |
| Insurance contract or identification number | WBT000922 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $6,296 | | Total amount of fees paid to insurance company | USD $2,396 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | 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 $53,736 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,296 | | Amount paid for insurance broker fees | 2396 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | 00 |
| Policy instance | 5 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $38,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 3 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $1,965 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,965 | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 6572 |
| Policy instance | 2 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $7,023 | | Total amount of fees paid to insurance company | USD $265 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $204,236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,023 | | Amount paid for insurance broker fees | 265 | | Additional information about fees paid to insurance broker | RETENTION BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | WBT000922 |
| Policy instance | 4 |
| Insurance contract or identification number | WBT000922 | | Number of Individuals Covered | 105 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $6,175 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | 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 $52,120 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,175 | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | V4775B ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | V4775B ET AL | | Number of Individuals Covered | 83 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $30,005 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $1,000,170 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,005 | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | 00 |
| Policy instance | 5 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $39,737 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | V4775B ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | V4775B ET AL | | Number of Individuals Covered | 86 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $27,422 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $914,070 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10008257 |
| Policy instance | 3 |
| Insurance contract or identification number | 10008257 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $2,060 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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 | 6572 |
| Policy instance | 2 |
| Insurance contract or identification number | 6572 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $5,593 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $164,737 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | WBT000922 |
| Policy instance | 4 |
| Insurance contract or identification number | WBT000922 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $6,554 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $55,913 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
