LEVI STRAUSS & CO. has sponsored the creation of one or more 401k plans.
Additional information about LEVI STRAUSS & CO.
Submission information for form 5500 for 401k plan LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES
401k plan membership statisitcs for LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES
| Measure | Date | Value |
|---|
| 2022: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 2,298 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 2,432 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 2 |
| Total of all active and inactive participants | 2022-01-01 | 2,434 |
| 2021: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 765 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 2,179 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 2 |
| Total of all active and inactive participants | 2021-01-01 | 2,181 |
| 2020: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 794 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 765 |
| Total of all active and inactive participants | 2020-01-01 | 765 |
| 2019: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 792 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 791 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 3 |
| Total of all active and inactive participants | 2019-01-01 | 794 |
| 2018: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 674 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 767 |
| Total of all active and inactive participants | 2018-01-01 | 767 |
| 2017: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 587 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 649 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 3 |
| Total of all active and inactive participants | 2017-01-01 | 652 |
| 2016: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 509 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 582 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 5 |
| Total of all active and inactive participants | 2016-01-01 | 587 |
| 2015: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-04-01 | 551 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-04-01 | 600 |
| Number of retired or separated participants receiving benefits | 2015-04-01 | 12 |
| Total of all active and inactive participants | 2015-04-01 | 612 |
| Total participants, beginning-of-year | 2015-01-01 | 571 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 492 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 17 |
| Total of all active and inactive participants | 2015-01-01 | 509 |
| 2014: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-04-01 | 634 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-04-01 | 573 |
| Number of retired or separated participants receiving benefits | 2014-04-01 | 3 |
| Total of all active and inactive participants | 2014-04-01 | 576 |
| 2013: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-04-01 | 610 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-04-01 | 630 |
| Number of retired or separated participants receiving benefits | 2013-04-01 | 4 |
| Total of all active and inactive participants | 2013-04-01 | 634 |
| 2012: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-04-01 | 595 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-04-01 | 603 |
| Number of retired or separated participants receiving benefits | 2012-04-01 | 7 |
| Total of all active and inactive participants | 2012-04-01 | 610 |
| 2011: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-04-01 | 558 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-04-01 | 593 |
| Number of retired or separated participants receiving benefits | 2011-04-01 | 2 |
| Total of all active and inactive participants | 2011-04-01 | 595 |
| 2022: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 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: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 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: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 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: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan 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 |
| 2015: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2015 form 5500 responses |
|---|
| 2015-04-01 | Type of plan entity | Single employer plan |
| 2015-04-01 | Plan funding arrangement – Insurance | Yes |
| 2015-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | Yes |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2014 form 5500 responses |
|---|
| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | Submission has been amended | Yes |
| 2014-04-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2012 form 5500 responses |
|---|
| 2012-04-01 | Type of plan entity | Single employer plan |
| 2012-04-01 | Submission has been amended | No |
| 2012-04-01 | This submission is the final filing | No |
| 2012-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-04-01 | Plan is a collectively bargained plan | No |
| 2012-04-01 | Plan funding arrangement – Insurance | Yes |
| 2012-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: LEVI STRAUSS & CO. CAFETERIA PLAN FOR RETAIL EMPLOYEES 2011 form 5500 responses |
|---|
| 2011-04-01 | Type of plan entity | Single employer plan |
| 2011-04-01 | Submission has been amended | No |
| 2011-04-01 | This submission is the final filing | No |
| 2011-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-04-01 | Plan is a collectively bargained plan | No |
| 2011-04-01 | Plan funding arrangement – Insurance | Yes |
| 2011-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 681637G/S09068 |
| Policy instance | 5 |
| Insurance contract or identification number | 681637G/S09068 | | Number of Individuals Covered | 2432 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $110,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 610581 |
| Policy instance | 4 |
| Insurance contract or identification number | G 610581 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $561 | | Total amount of fees paid to insurance company | USD $19 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,740 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $561 | | Amount paid for insurance broker fees | 19 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 130392 |
| Policy instance | 3 |
| Insurance contract or identification number | LTD 130392 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $3,448 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $41,366 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3448 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00112676 |
| Policy instance | 2 |
| Insurance contract or identification number | 00112676 | | Number of Individuals Covered | 489 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $100,371 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 1 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,325 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 1 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,648 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00112676 |
| Policy instance | 2 |
| Insurance contract or identification number | 00112676 | | Number of Individuals Covered | 461 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $99,135 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 130392 |
| Policy instance | 3 |
| Insurance contract or identification number | LTD 130392 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $3,593 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,029 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3593 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 610581 |
| Policy instance | 4 |
| Insurance contract or identification number | G 610581 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $558 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $558 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 681637G/S09068 |
| Policy instance | 5 |
| Insurance contract or identification number | 681637G/S09068 | | Number of Individuals Covered | 2179 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $93,213 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 1 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,285 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00112676 |
| Policy instance | 2 |
| Insurance contract or identification number | 00112676 | | Number of Individuals Covered | 444 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $103,488 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 130392 |
| Policy instance | 3 |
| Insurance contract or identification number | LTD 130392 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $20,000 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,088 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 20000 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 610581 |
| Policy instance | 4 |
| Insurance contract or identification number | G 610581 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,000 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 681637G/S09068 |
| Policy instance | 5 |
| Insurance contract or identification number | 681637G/S09068 | | Number of Individuals Covered | 2620 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $121,115 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 1 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,295 | | 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 | 0165672 |
| Policy instance | 2 |
| Insurance contract or identification number | 0165672 | | Number of Individuals Covered | 791 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $42 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $39,457 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 42 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00112676 |
| Policy instance | 3 |
| Insurance contract or identification number | 00112676 | | Number of Individuals Covered | 386 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $82,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 130392 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD 130392 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,134 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 610581 |
| Policy instance | 5 |
| Insurance contract or identification number | G 610581 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,071 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,140 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,071 | | Insurance broker organization code? | 3 |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF386003934401 |
| Policy instance | 1 |
| Insurance contract or identification number | GF386003934401 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,046 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 2 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,298 | | 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: 62146 ) |
| Policy contract number | 9703463 |
| Policy instance | 3 |
| Insurance contract or identification number | 9703463 | | Number of Individuals Covered | 862 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10 | | 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 | 0165672 |
| Policy instance | 4 |
| Insurance contract or identification number | 0165672 | | Number of Individuals Covered | 767 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $70 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $34,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 70 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00112676 |
| Policy instance | 5 |
| Insurance contract or identification number | 00112676 | | Number of Individuals Covered | 318 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,440 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF386003934401 |
| Policy instance | 6 |
| Insurance contract or identification number | GF386003934401 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,310 | | 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 | 0165672 |
| Policy instance | 4 |
| Insurance contract or identification number | 0165672 | | Number of Individuals Covered | 772 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $6,047 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $28,177 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 6000 | | Additional information about fees paid to insurance broker | ADMINISTRATON FEES AND NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER US INC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9703463 |
| Policy instance | 3 |
| Insurance contract or identification number | 9703463 | | Number of Individuals Covered | 864 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,755 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 2 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF386003934401 |
| Policy instance | 1 |
| Insurance contract or identification number | GF386003934401 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2016-12-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,163 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 319863-LOS |
| Policy instance | 1 |
| Insurance contract or identification number | 319863-LOS | | Number of Individuals Covered | 720 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF386003934401 |
| Policy instance | 2 |
| Insurance contract or identification number | GF386003934401 | | Number of Individuals Covered | 179 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,171 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 3 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,537 | | 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: 62146 ) |
| Policy contract number | 9703463 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703463 | | Number of Individuals Covered | 623 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,505 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 ) |
| Policy contract number | 79-860229 |
| Policy instance | 5 |
| Insurance contract or identification number | 79-860229 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 3 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $65,133 | | 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: 62146 ) |
| Policy contract number | 9703463 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703463 | | Number of Individuals Covered | 607 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,308 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 319863-LOS |
| Policy instance | 1 |
| Insurance contract or identification number | 319863-LOS | | Number of Individuals Covered | 575 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF386003934401 |
| Policy instance | 2 |
| Insurance contract or identification number | GF386003934401 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,792 | | 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: 62146 ) |
| Policy contract number | 9703463 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703463 | | Number of Individuals Covered | 603 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,540 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 3 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $78,881 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF386003934401 |
| Policy instance | 2 |
| Insurance contract or identification number | GF386003934401 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,288 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 319863-ERG-LOS |
| Policy instance | 1 |
| Insurance contract or identification number | 319863-ERG-LOS | | Number of Individuals Covered | 658 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 ) |
| Policy contract number | 79-860229 |
| Policy instance | 5 |
| Insurance contract or identification number | 79-860229 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 ) |
| Policy contract number | 79-860229 |
| Policy instance | 5 |
| Insurance contract or identification number | 79-860229 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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: 62146 ) |
| Policy contract number | 9703463 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703463 | | Number of Individuals Covered | 550 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 | 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 $8,685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 3 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $65,819 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF386003934401 |
| Policy instance | 2 |
| Insurance contract or identification number | GF386003934401 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $37,710 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 319863-ERG-LOS |
| Policy instance | 1 |
| Insurance contract or identification number | 319863-ERG-LOS | | Number of Individuals Covered | 657 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP9109516 |
| Policy instance | 5 |
| Insurance contract or identification number | GTP9109516 | | Number of Individuals Covered | 611 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $50 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD & D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $200 | | 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: 62146 ) |
| Policy contract number | 9703463 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703463 | | Number of Individuals Covered | 551 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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 | 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 $8,325 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 3 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $67,802 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF386003934401 |
| Policy instance | 2 |
| Insurance contract or identification number | GF386003934401 | | Number of Individuals Covered | 219 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $45,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 319863-LP |
| Policy instance | 1 |
| Insurance contract or identification number | 319863-LP | | Number of Individuals Covered | 654 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 ) |
| Policy contract number | 79-860229 |
| Policy instance | 6 |
| Insurance contract or identification number | 79-860229 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2011-12-31 | | 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9703463 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703463 | | Number of Individuals Covered | 617 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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 | 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 $4,579 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 4567-11 |
| Policy instance | 3 |
| Insurance contract or identification number | 4567-11 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2010-12-31 | | 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $53,078 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other welfare benefits provided | LEGAL |
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| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF386003934401 |
| Policy instance | 2 |
| Insurance contract or identification number | GF386003934401 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2010-11-30 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,648 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 319863-LP |
| Policy instance | 1 |
| Insurance contract or identification number | 319863-LP | | Number of Individuals Covered | 576 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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