401k Plan data: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN plan

CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN
Plan identification number	501

CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision

401k Sponsoring company profile

CALIFORNIA HYDRONICS CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: CALIFORNIA HYDRONICS CORPORATION

Employer identification number (EIN): 941394204

NAIC Classification: 423700

Additional information about CALIFORNIA HYDRONICS CORPORATION

Jurisdiction of Incorporation: California Department of State

Incorporation Date:

Company Identification Number: C0343539

More information about CALIFORNIA HYDRONICS CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 DONNA KRONENBERG
501 2017-01-01 DONNA KRONENBERG
501 2016-01-01 DONNA KRONENBERG
501 2015-01-01 DONNA KRONENBERG
501 2014-01-01 DONNA KRONENBERG
501 2013-01-01 DONNA KRONENBERG
501 2012-01-01 DONNA KRONENBERG
501 2011-01-01 DONNA KRONENBERG
501 2010-01-01 DONNA KRONENBERG
501 2009-01-01 DONNA KRONENBERG
501 2008-01-01
501 2007-01-01 DONNA KRONENBERG DONNA KRONENBERG 2011-02-16

Plan Statistics for CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN

401k plan membership statisitcs for CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN

Measure Date Value
2022: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 147
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 155
Total of all active and inactive participants 2022-01-01 155
Total participants 2022-01-01 155
2021: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 156
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 147
Total of all active and inactive participants 2021-01-01 147
Total participants 2021-01-01 147
2020: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 150
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 156
Total of all active and inactive participants 2020-01-01 156
Total participants 2020-01-01 156
2019: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 150
Total of all active and inactive participants 2019-01-01 150
Total participants 2019-01-01 150
Number of participants with account balances 2019-01-01 0
2018: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 150
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 145
Total of all active and inactive participants 2018-01-01 145
Total participants 2018-01-01 145
2017: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 142
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 150
Total of all active and inactive participants 2017-01-01 150
Total participants 2017-01-01 150
2016: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 142
Number of retired or separated participants receiving benefits 2016-01-01 4
Total of all active and inactive participants 2016-01-01 146
Total participants 2016-01-01 0
2015: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 141
Number of retired or separated participants receiving benefits 2015-01-01 3
Total of all active and inactive participants 2015-01-01 144
Total participants 2015-01-01 0
2014: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 115
Total of all active and inactive participants 2014-01-01 115
Total participants 2014-01-01 0
2013: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 128
Total of all active and inactive participants 2013-01-01 128
Total participants 2013-01-01 0
2012: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 113
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 129
Total of all active and inactive participants 2012-01-01 129
Total participants 2012-01-01 0
2011: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 113
Total of all active and inactive participants 2011-01-01 0
Total participants 2011-01-01 0
2010: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 147
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 113
Total of all active and inactive participants 2010-01-01 113
Total participants 2010-01-01 113
2009: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 163
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 147
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 147
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
2007: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2007 401k membership
Total participants, beginning-of-year 2007-01-01 176
Total number of active participants reported on line 7a of the Form 5500 2007-01-01 176
Number of retired or separated participants receiving benefits 2007-01-01 0
Number of other retired or separated participants entitled to future benefits 2007-01-01 0
Total of all active and inactive participants 2007-01-01 176
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2007-01-01 0

Measure	Date	Value
2022: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	147
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	155
Total of all active and inactive participants	2022-01-01	155
Total participants	2022-01-01	155
2021: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	156
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	147
Total of all active and inactive participants	2021-01-01	147
Total participants	2021-01-01	147
2020: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	150
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	156
Total of all active and inactive participants	2020-01-01	156
Total participants	2020-01-01	156
2019: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	150
Total of all active and inactive participants	2019-01-01	150
Total participants	2019-01-01	150
Number of participants with account balances	2019-01-01	0
2018: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	150
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	145
Total of all active and inactive participants	2018-01-01	145
Total participants	2018-01-01	145
2017: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	142
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	150
Total of all active and inactive participants	2017-01-01	150
Total participants	2017-01-01	150
2016: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	142
Number of retired or separated participants receiving benefits	2016-01-01	4
Total of all active and inactive participants	2016-01-01	146
Total participants	2016-01-01	0
2015: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	141
Number of retired or separated participants receiving benefits	2015-01-01	3
Total of all active and inactive participants	2015-01-01	144
Total participants	2015-01-01	0
2014: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	115
Total of all active and inactive participants	2014-01-01	115
Total participants	2014-01-01	0
2013: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	128
Total of all active and inactive participants	2013-01-01	128
Total participants	2013-01-01	0
2012: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	113
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	129
Total of all active and inactive participants	2012-01-01	129
Total participants	2012-01-01	0
2011: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	113
Total of all active and inactive participants	2011-01-01	0
Total participants	2011-01-01	0
2010: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	147
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	113
Total of all active and inactive participants	2010-01-01	113
Total participants	2010-01-01	113
2009: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	163
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	147
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	147
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
2007: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2007 401k membership
Total participants, beginning-of-year	2007-01-01	176
Total number of active participants reported on line 7a of the Form 5500	2007-01-01	176
Number of retired or separated participants receiving benefits	2007-01-01	0
Number of other retired or separated participants entitled to future benefits	2007-01-01	0
Total of all active and inactive participants	2007-01-01	176
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2007-01-01	0

Form 5500 Responses for CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN

2022: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT 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 benefit arrangement – Insurance	Yes
2018: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT 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 benefit arrangement – Insurance	Yes
2017: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT 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 benefit arrangement – Insurance	Yes
2016: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2008: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2008 form 5500 responses
2008-01-01	Type of plan entity	Single employer plan
2008-01-01	Submission has been amended	No
2008-01-01	This submission is the final filing	No
2008-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-01-01	Plan is a collectively bargained plan	No
2007: CALIFORNIA HYDRONICS CORPORATION WELFARE BENEFIT PLAN 2007 form 5500 responses
2007-01-01	Type of plan entity	Single employer plan
2007-01-01	Submission has been amended	No
2007-01-01	This submission is the final filing	No
2007-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2007-01-01	Plan is a collectively bargained plan	No
2007-01-01	Plan funding arrangement – Insurance	Yes
2007-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001019

Policy instance

Insurance contract or identification number	W0001019
Number of Individuals Covered	52
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $37,631
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,211,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	37631
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	61
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-01
Total amount of commissions paid to insurance broker	USD $7,523
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $370,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,523
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	128
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-01
Total amount of commissions paid to insurance broker	USD $25,133
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $916,373
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,133
Insurance broker organization code?	3

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	13
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,634
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,634
Insurance broker organization code?	3

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

002038

Policy instance

Insurance contract or identification number	002038
Number of Individuals Covered	143
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $172
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $5,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $172
Insurance broker organization code?	3

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

Policy contract number

E7910920

Policy instance

Insurance contract or identification number	E7910920
Number of Individuals Covered	13
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-01
Total amount of commissions paid to insurance broker	USD $360
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $199
Insurance broker organization code?	3

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

Policy contract number

1032619

Policy instance

Insurance contract or identification number	1032619
Number of Individuals Covered	358
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $9,096
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $303,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9096

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30037270

Policy instance

Insurance contract or identification number	30037270
Number of Individuals Covered	143
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,022
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $721
Insurance broker organization code?	3

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	74
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-01
Total amount of commissions paid to insurance broker	USD $8,686
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $431,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,686
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	110
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-01
Total amount of commissions paid to insurance broker	USD $24,355
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,355
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001019

Policy instance

Insurance contract or identification number	W0001019
Number of Individuals Covered	55
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $41,297
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,328,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	41297
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

002038

Policy instance

Insurance contract or identification number	002038
Number of Individuals Covered	143
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $186
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $6,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $186
Insurance broker organization code?	3

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

Policy contract number

E7910920

Policy instance

Insurance contract or identification number	E7910920
Number of Individuals Covered	18
Total amount of commissions paid to insurance broker	USD $656
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $294
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30037270

Policy instance

Insurance contract or identification number	30037270
Number of Individuals Covered	142
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,296
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $915
Insurance broker organization code?	3

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	12
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,042
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,042
Insurance broker organization code?	3

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

Policy contract number

1032619

Policy instance

Insurance contract or identification number	1032619
Number of Individuals Covered	362
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-01
Total amount of commissions paid to insurance broker	USD $9,191
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $306,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,191
Insurance broker organization code?	3

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	77
Total amount of commissions paid to insurance broker	USD $8,340
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $419,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,340
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001019

Policy instance

Insurance contract or identification number	W0001019
Number of Individuals Covered	123
Total amount of fees paid to insurance company	USD $42,690
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,368,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	42690
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

002038

Policy instance

Insurance contract or identification number	002038
Number of Individuals Covered	143
Total amount of commissions paid to insurance broker	USD $186
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $6,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $186
Insurance broker organization code?	3

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

Policy contract number

E7910920

Policy instance

Insurance contract or identification number	E7910920
Number of Individuals Covered	23
Total amount of commissions paid to insurance broker	USD $917
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $366
Insurance broker organization code?	3

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

Policy contract number

1032619

Policy instance

Insurance contract or identification number	1032619
Number of Individuals Covered	375
Total amount of commissions paid to insurance broker	USD $9,033
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $291,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,033

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30037270

Policy instance

Insurance contract or identification number	30037270
Number of Individuals Covered	143
Total amount of commissions paid to insurance broker	USD $541
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $541
Insurance broker organization code?	3

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	12
Total amount of commissions paid to insurance broker	USD $2,831
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $98,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,831
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	115
Total amount of commissions paid to insurance broker	USD $24,771
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $764,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,771
Insurance broker organization code?	3

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	77
Total amount of commissions paid to insurance broker	USD $9,405
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $439,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,405
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	108
Total amount of commissions paid to insurance broker	USD $21,616
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $721,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,616
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001019

Policy instance

Insurance contract or identification number	W0001019
Number of Individuals Covered	114
Total amount of commissions paid to insurance broker	USD $30
Total amount of fees paid to insurance company	USD $37,330
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,208,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30
Amount paid for insurance broker fees	37330
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

002038

Policy instance

Insurance contract or identification number	002038
Number of Individuals Covered	143
Total amount of commissions paid to insurance broker	USD $186
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $6,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $186
Insurance broker organization code?	3

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

Policy contract number

E7910920

Policy instance

Insurance contract or identification number	E7910920
Number of Individuals Covered	24
Total amount of commissions paid to insurance broker	USD $920
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $399
Insurance broker organization code?	3

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

Policy contract number

1032619

Policy instance

Insurance contract or identification number	1032619
Number of Individuals Covered	362
Total amount of commissions paid to insurance broker	USD $8,532
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $261,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,532

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30037270

Policy instance

Insurance contract or identification number	30037270
Number of Individuals Covered	139
Total amount of commissions paid to insurance broker	USD $713
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $713
Insurance broker organization code?	3

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	16
Total amount of commissions paid to insurance broker	USD $2,261
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,261
Insurance broker organization code?	3

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	75
Total amount of commissions paid to insurance broker	USD $7,664
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $386,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,664
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	121
Total amount of commissions paid to insurance broker	USD $21,996
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $726,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,996
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001019

Policy instance

Insurance contract or identification number	W0001019
Number of Individuals Covered	117
Total amount of commissions paid to insurance broker	USD $34,405
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,146,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,405
Insurance broker organization code?	3

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

Policy contract number

E7910920

Policy instance

Insurance contract or identification number	E7910920
Number of Individuals Covered	27
Total amount of commissions paid to insurance broker	USD $1,150
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $313
Insurance broker organization code?	3

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

002038

Policy instance

Insurance contract or identification number	002038
Number of Individuals Covered	143
Total amount of commissions paid to insurance broker	USD $186
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $6,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $186
Insurance broker organization code?	3

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

Policy contract number

1032619

Policy instance

Insurance contract or identification number	1032619
Number of Individuals Covered	369
Total amount of commissions paid to insurance broker	USD $8,514
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $307,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,514

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30037270

Policy instance

Insurance contract or identification number	30037270
Number of Individuals Covered	133
Total amount of commissions paid to insurance broker	USD $652
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $652
Insurance broker organization code?	3

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	8
Total amount of commissions paid to insurance broker	USD $1,099
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,099
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001019

Policy instance

Insurance contract or identification number	W0001019
Number of Individuals Covered	117
Total amount of commissions paid to insurance broker	USD $33,011
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,100,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,011
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVIES

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

002038

Policy instance

Insurance contract or identification number	002038
Number of Individuals Covered	128
Total amount of commissions paid to insurance broker	USD $198
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $6,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $198
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

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

Policy contract number

E7910920

Policy instance

Insurance contract or identification number	E7910920
Number of Individuals Covered	28
Total amount of commissions paid to insurance broker	USD $1,598
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $412
Insurance broker organization code?	4
Insurance broker name	CHEYRL D SMITH

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

Policy contract number

1032619

Policy instance

Insurance contract or identification number	1032619
Number of Individuals Covered	382
Total amount of commissions paid to insurance broker	USD $8,943
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $293,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,943
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30037270

Policy instance

Insurance contract or identification number	30037270
Number of Individuals Covered	141
Total amount of commissions paid to insurance broker	USD $664
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $664
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	7
Total amount of commissions paid to insurance broker	USD $1,600
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,600
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	131
Total amount of commissions paid to insurance broker	USD $21,828
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $795,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,828
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	78
Total amount of commissions paid to insurance broker	USD $6,589
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $359,653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,589
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30037270

Policy instance

Insurance contract or identification number	30037270
Number of Individuals Covered	127
Total amount of commissions paid to insurance broker	USD $588
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $588
Insurance broker organization code?	3
Insurance broker name	ALLAN MARK WISER

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

Policy contract number

1032619

Policy instance

Insurance contract or identification number	1032619
Number of Individuals Covered	357
Total amount of commissions paid to insurance broker	USD $7,470
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $247,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,348
Insurance broker organization code?	3
Insurance broker name	ALLAN MARK WISER

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

Policy contract number

E7910920

Policy instance

Insurance contract or identification number	E7910920
Total amount of commissions paid to insurance broker	USD $1,968
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $623
Insurance broker organization code?	4
Additional information about fees paid to insurance broker	BONUSES
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

2038

Policy instance

Insurance contract or identification number	2038
Number of Individuals Covered	141
Total amount of commissions paid to insurance broker	USD $189
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $3,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $189
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	8
Total amount of commissions paid to insurance broker	USD $1,102
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,102
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001019

Policy instance

Insurance contract or identification number	W0001019
Number of Individuals Covered	92
Total amount of commissions paid to insurance broker	USD $22,212
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $740,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,212
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVIES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	135
Total amount of commissions paid to insurance broker	USD $25,071
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $837,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,071
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	74
Total amount of commissions paid to insurance broker	USD $9,571
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $353,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,571
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30037270

Policy instance

Insurance contract or identification number	30037270
Number of Individuals Covered	119
Total amount of commissions paid to insurance broker	USD $537
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,893
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
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	4
Total amount of commissions paid to insurance broker	USD $1,090
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,090
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001019

Policy instance

Insurance contract or identification number	W0001019
Number of Individuals Covered	96
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $21,841
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $736,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,841
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVIES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	115
Total amount of commissions paid to insurance broker	USD $14,996
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $716,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,996
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	65
Total amount of commissions paid to insurance broker	USD $7,530
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $278,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,530
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

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

Policy contract number

E7910920

Policy instance

Insurance contract or identification number	E7910920
Number of Individuals Covered	35
Total amount of commissions paid to insurance broker	USD $1,970
Total amount of fees paid to insurance company	USD $84
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $610
Insurance broker organization code?	4
Amount paid for insurance broker fees	3
Additional information about fees paid to insurance broker	BONUSES
Insurance broker name	CHRISTINE LYNN MORGESTER

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

Policy contract number

1032619

Policy instance

Insurance contract or identification number	1032619
Number of Individuals Covered	335
Total amount of commissions paid to insurance broker	USD $7,095
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $237,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,095
Insurance broker organization code?	3
Insurance broker name	ALLAN MARK WISER

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

2038

Policy instance

Insurance contract or identification number	2038
Number of Individuals Covered	132
Total amount of commissions paid to insurance broker	USD $161
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $3,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $161
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

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

Policy contract number

E7910920

Policy instance

Insurance contract or identification number	E7910920
Number of Individuals Covered	36
Total amount of commissions paid to insurance broker	USD $2,909
Total amount of fees paid to insurance company	USD $153
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $829
Insurance broker organization code?	3
Amount paid for insurance broker fees	7
Additional information about fees paid to insurance broker	BONUSES
Insurance broker name	HOLLERN & ASSOCIATES INCORPORATED

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

2038

Policy instance

Insurance contract or identification number	2038
Number of Individuals Covered	130
Total amount of commissions paid to insurance broker	USD $173
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $3,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $173
Insurance broker organization code?	3
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	6
Total amount of commissions paid to insurance broker	USD $1,280
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,280
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

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

Policy contract number

1032619

Policy instance

Insurance contract or identification number	1032619
Number of Individuals Covered	326
Total amount of commissions paid to insurance broker	USD $6,760
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $226,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,760
Insurance broker name	ALLAN MARK WISER

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

Policy contract number

KM05584085

Policy instance

Insurance contract or identification number	KM05584085
Total amount of commissions paid to insurance broker	USD $751
Total amount of fees paid to insurance company	USD $291
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $751
Insurance broker organization code?	3
Amount paid for insurance broker fees	291
Additional information about fees paid to insurance broker	GROSS DEALER CONCESSION
Insurance broker name	NEW ENGLAND FINANCIAL/SECURITIES

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30037270

Policy instance

Insurance contract or identification number	30037270
Number of Individuals Covered	113
Total amount of commissions paid to insurance broker	USD $531
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $531
Insurance broker name	ALLAN WISER INSURANCE SERVIES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	113
Total amount of commissions paid to insurance broker	USD $25,538
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $635,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,538
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	70
Total amount of commissions paid to insurance broker	USD $8,952
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $263,227
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,952
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0001019

Policy instance

Insurance contract or identification number	W0001019
Number of Individuals Covered	103
Total amount of commissions paid to insurance broker	USD $22,772
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $759,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,772
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

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

Policy contract number

E7910920

Policy instance

Insurance contract or identification number	E7910920
Number of Individuals Covered	40
Total amount of commissions paid to insurance broker	USD $5,186
Total amount of fees paid to insurance company	USD $464
Welfare Benefit Premiums Paid to Carrier	USD $28,942
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
Amount paid for insurance broker fees	1
Additional information about fees paid to insurance broker	BONUSES
Insurance broker organization code?	4
Insurance broker name	LISA M KELLEY

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

2038

Policy instance

Insurance contract or identification number	2038
Number of Individuals Covered	130
Total amount of commissions paid to insurance broker	USD $171
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $3,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58
Insurance broker organization code?	3
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	14
Total amount of commissions paid to insurance broker	USD $714
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $714
Insurance broker organization code?	3
Insurance broker name	ALLAN WISER INSURANCE SERVICES INC

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

931297

Policy instance

Insurance contract or identification number	931297
Number of Individuals Covered	106
Total amount of commissions paid to insurance broker	USD $35,141
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $776,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,572
Insurance broker organization code?	3
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

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

Policy contract number

KM05584085

Policy instance

Insurance contract or identification number	KM05584085
Number of Individuals Covered	507
Total amount of commissions paid to insurance broker	USD $11,103
Total amount of fees paid to insurance company	USD $847
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $237,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	847
Additional information about fees paid to insurance broker	GROSS DEALER CONCESSION
Insurance broker organization code?	4
Commission paid to Insurance Broker	USD $2,179
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	132
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $613,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	68
Total amount of commissions paid to insurance broker	USD $8,767
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $228,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,215
Insurance broker organization code?	3
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

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

Policy contract number

9741133

Policy instance

Insurance contract or identification number	9741133
Number of Individuals Covered	302
Total amount of commissions paid to insurance broker	USD $1,249
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $315
Insurance broker organization code?	3
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	15
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,236
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

KM05584085

Policy instance

Insurance contract or identification number	KM05584085
Number of Individuals Covered	494
Total amount of commissions paid to insurance broker	USD $10,292
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $217,525
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

9741133

Policy instance

Insurance contract or identification number	9741133
Number of Individuals Covered	292
Total amount of commissions paid to insurance broker	USD $1,212
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	63
Total amount of commissions paid to insurance broker	USD $7,821
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $217,167
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

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	126
Total amount of commissions paid to insurance broker	USD $1,051
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $520,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 )

Policy contract number

2038

Policy instance

Insurance contract or identification number	2038
Number of Individuals Covered	127
Total amount of commissions paid to insurance broker	USD $169
Other welfare benefits provided	EAP PLAN PREMIUMS
Welfare Benefit Premiums Paid to Carrier	USD $3,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

931297

Policy instance

Insurance contract or identification number	931297
Number of Individuals Covered	108
Total amount of commissions paid to insurance broker	USD $34,062
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $662,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12535

Policy instance

Insurance contract or identification number	12535
Number of Individuals Covered	49
Total amount of commissions paid to insurance broker	USD $601
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $147,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $601
Insurance broker organization code?	4
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

931297

Policy instance

Insurance contract or identification number	931297
Number of Individuals Covered	140
Total amount of commissions paid to insurance broker	USD $37,744
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $757,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,744
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

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

Policy contract number

9741133

Policy instance

Insurance contract or identification number	9741133
Number of Individuals Covered	289
Total amount of commissions paid to insurance broker	USD $1,227
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,227
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

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

Policy contract number

KM05584085

Policy instance

Insurance contract or identification number	KM05584085
Number of Individuals Covered	476
Total amount of commissions paid to insurance broker	USD $10,149
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $198,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,149
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

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

Policy contract number

1249100

Policy instance

Insurance contract or identification number	1249100
Number of Individuals Covered	7
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,785
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

600784

Policy instance

Insurance contract or identification number	600784
Number of Individuals Covered	112
Total amount of commissions paid to insurance broker	USD $3,045
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $434,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,045
Insurance broker name	SALSBURY & ASSOCIATES INS SVCS INC

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Company Name:	CALIFORNIA HYDRONICS CORPORATION
Employer identification number (EIN):	941394204
NAIC Classification:	423700

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	C0343539