401k Plan data: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN plan

EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN
Plan identification number	502

EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

KOOSHAREM LLC DBA SELECT STAFFING, INC. has sponsored the creation of one or more 401k plans.

Company Name: KOOSHAREM LLC DBA SELECT STAFFING, INC.

Employer identification number (EIN): 930994537

NAIC Classification: 561490

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2019-01-01
502 2018-01-01
502 2017-01-01 ROB THRESHER
502 2016-01-01 TOM MEADE

Plan Statistics for EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN

401k plan membership statisitcs for EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN

Measure Date Value
2019: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 7,731
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 8,118
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 8,118
2018: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 4,518
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 7,731
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 7,731
2017: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 8,036
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 4,518
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 4,518
2016: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 2,000
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 8,036
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 8,036

Measure	Date	Value
2019: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	7,731
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	8,118
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	8,118
2018: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	4,518
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	7,731
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	7,731
2017: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	8,036
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	4,518
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	4,518
2016: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	2,000
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	8,036
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	8,036

Form 5500 Responses for EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN

2019: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: EMPLOYBRIDGE HOLDING COMPANY ASSOCIATES WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	First time form 5500 has been submitted	Yes
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

MEC1301

Policy instance

Insurance contract or identification number	MEC1301
Number of Individuals Covered	7774
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $1,171,651
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	610894
Additional information about fees paid to insurance broker	ADMIN FEE
Insurance broker organization code?	3

HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 )

Policy contract number

5538,53135

Policy instance

Insurance contract or identification number	5538,53135
Number of Individuals Covered	52
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,248
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $176,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,248
Insurance broker organization code?	3

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

Policy contract number

5799

Policy instance

Insurance contract or identification number	5799
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $50
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50
Insurance broker organization code?	3

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

Policy contract number

70122-0

Policy instance

Insurance contract or identification number	70122-0
Number of Individuals Covered	5893
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $24,037
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $122,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	24037
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

AM1301

Policy instance

Insurance contract or identification number	AM1301
Number of Individuals Covered	10776
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $424,436
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,738,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $273,830
Insurance broker organization code?	3

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

FV1301

Policy instance

Insurance contract or identification number	FV1301
Number of Individuals Covered	11544
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $564,386
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,469,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $464,890
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10029591002

Policy instance

Insurance contract or identification number	10029591002
Number of Individuals Covered	804
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,116
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,116
Insurance broker organization code?	3

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

278883

Policy instance

Insurance contract or identification number	278883
Number of Individuals Covered	242
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,025,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

278883

Policy instance

Insurance contract or identification number	278883
Number of Individuals Covered	380
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $24,708
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,548,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	24708
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 )

Policy contract number

53984

Policy instance

Insurance contract or identification number	53984
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $772
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $772
Insurance broker organization code?	3

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

278883

Policy instance

Insurance contract or identification number	278883
Number of Individuals Covered	349
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,198,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10029591002

Policy instance

Insurance contract or identification number	10029591002
Number of Individuals Covered	773
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $14,824
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,824
Insurance broker organization code?	3

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

FV1301

Policy instance

Insurance contract or identification number	FV1301
Number of Individuals Covered	7290
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $476,487
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,655,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $395,738
Insurance broker organization code?	3

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

AM1301

Policy instance

Insurance contract or identification number	AM1301
Number of Individuals Covered	10484
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $350,926
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,264,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $226,404
Insurance broker organization code?	3

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

Policy contract number

5799

Policy instance

Insurance contract or identification number	5799
Number of Individuals Covered	7
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $89
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89
Insurance broker organization code?	3

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

MEC1301

Policy instance

Insurance contract or identification number	MEC1301
Number of Individuals Covered	8515
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of fees paid to insurance company	USD $868,643
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	427176
Additional information about fees paid to insurance broker	ADMIN FEE
Insurance broker organization code?	3

HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 )

Policy contract number

5538,53135

Policy instance

Insurance contract or identification number	5538,53135
Number of Individuals Covered	64
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,177
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $177,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,177
Insurance broker organization code?	3

HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 )

Policy contract number

53984

Policy instance

Insurance contract or identification number	53984
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 $1,073
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,085
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,073
Insurance broker organization code?	3

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

278883

Policy instance

Insurance contract or identification number	278883
Number of Individuals Covered	630
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,375,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

162460BR2

Policy instance

Insurance contract or identification number	162460BR2
Number of Individuals Covered	1918
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $21,517
Total amount of fees paid to insurance company	USD $3,731
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $148,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,517
Amount paid for insurance broker fees	3731
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?	3

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

278883

Policy instance

Insurance contract or identification number	278883
Number of Individuals Covered	523
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,393,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Total amount of commissions paid to insurance broker	USD $18,124
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
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
Commission paid to Insurance Broker	USD $18,124
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10029591002

Policy instance

Insurance contract or identification number	10029591002
Number of Individuals Covered	759
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

FV1301

Policy instance

Insurance contract or identification number	FV1301
Number of Individuals Covered	5978
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $632,619
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,326,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $537,726
Insurance broker organization code?	3
Insurance broker name	FRINGE INSURANCE BENEFITS, INC.

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

AM1301

Policy instance

Insurance contract or identification number	AM1301
Number of Individuals Covered	6311
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $393,328
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,537,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $253,760
Insurance broker organization code?	3
Insurance broker name	FRING INSURANCE BENEFITS, INC.

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

MEC1301

Policy instance

Insurance contract or identification number	MEC1301
Number of Individuals Covered	4339
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $605,147
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	217329
Additional information about fees paid to insurance broker	BROKER FEE
Insurance broker organization code?	3
Insurance broker name	FIRST HEALTH

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

Policy contract number

5799

Policy instance

Insurance contract or identification number	5799
Number of Individuals Covered	13
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $150
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $150
Insurance broker organization code?	3
Insurance broker name	PSH INSURANCE, INC.

HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 )

Policy contract number

5538,53135

Policy instance

Insurance contract or identification number	5538,53135
Number of Individuals Covered	47
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,801
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $152,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,801
Insurance broker organization code?	3
Insurance broker name	P.S.H. INSURANCE, INC.

HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 )

Policy contract number

53984

Policy instance

Insurance contract or identification number	53984
Number of Individuals Covered	10
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,532
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,532
Insurance broker organization code?	3
Insurance broker name	P.S.H. INSURANCE

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

Policy contract number

162460BR2

Policy instance

Insurance contract or identification number	162460BR2
Number of Individuals Covered	1468
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $54,650
Total amount of fees paid to insurance company	USD $7,694
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $451,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,650
Amount paid for insurance broker fees	7694
Additional information about fees paid to insurance broker	NON-MONETARY/ADDITIONAL COMP. ADMIN FEES
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

278883

Policy instance

Insurance contract or identification number	278883
Number of Individuals Covered	1017
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $20,666
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,367,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,666
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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Company Name:	KOOSHAREM LLC DBA SELECT STAFFING, INC.
Employer identification number (EIN):	930994537
NAIC Classification:	561490