CYPRESS SEMICONDUCTOR CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SPANSION COMPREHENSIVE WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022 : SPANSION COMPREHENSIVE WELFARE PLAN 2022 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2022-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-12-31 | $905,603 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-12-31 | $0 |
| Total income from all sources (including contributions) | 2022-12-31 | $0 |
| Total loss/gain on sale of assets | 2022-12-31 | $0 |
| Total of all expenses incurred | 2022-12-31 | $905,603 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-12-31 | $905,603 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-12-31 | $0 |
| Value of total assets at end of year | 2022-12-31 | $905,603 |
| Value of total assets at beginning of year | 2022-12-31 | $905,603 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-12-31 | $0 |
| Total interest from all sources | 2022-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2022-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-12-31 | Yes |
| Was this plan covered by a fidelity bond | 2022-12-31 | Yes |
| Value of fidelity bond cover | 2022-12-31 | $5,000,000 |
| If this is an individual account plan, was there a blackout period | 2022-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2022-12-31 | No |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2022-12-31 | $905,603 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2022-12-31 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2022-12-31 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2022-12-31 | $905,603 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2022-12-31 | $0 |
| Total non interest bearing cash at end of year | 2022-12-31 | $905,603 |
| Total non interest bearing cash at beginning of year | 2022-12-31 | $905,603 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Value of net income/loss | 2022-12-31 | $-905,603 |
| Value of net assets at end of year (total assets less liabilities) | 2022-12-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2022-12-31 | $905,603 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2022-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2022-12-31 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2022-12-31 | $0 |
| Did the plan have assets held for investment | 2022-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2022-12-31 | Unqualified |
| Accountancy firm name | 2022-12-31 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2022-12-31 | 910189318 |
| 2021 : SPANSION COMPREHENSIVE WELFARE PLAN 2021 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2021-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $930,813 |
| Total income from all sources (including contributions) | 2021-12-31 | $0 |
| Total loss/gain on sale of assets | 2021-12-31 | $0 |
| Total of all expenses incurred | 2021-12-31 | $-738,544 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $-738,544 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $0 |
| Value of total assets at end of year | 2021-12-31 | $905,603 |
| Value of total assets at beginning of year | 2021-12-31 | $1,097,872 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $0 |
| Total interest from all sources | 2021-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2021-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | Yes |
| Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan | 2021-12-31 | $0 |
| Was this plan covered by a fidelity bond | 2021-12-31 | Yes |
| Value of fidelity bond cover | 2021-12-31 | $5,000,000 |
| If this is an individual account plan, was there a blackout period | 2021-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-12-31 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-12-31 | $117,645 |
| Total non interest bearing cash at end of year | 2021-12-31 | $905,603 |
| Total non interest bearing cash at beginning of year | 2021-12-31 | $980,227 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Value of net income/loss | 2021-12-31 | $738,544 |
| Value of net assets at end of year (total assets less liabilities) | 2021-12-31 | $905,603 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-12-31 | $167,059 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-12-31 | $-738,544 |
| Liabilities. Value of benefit claims payable at end of year | 2021-12-31 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2021-12-31 | $930,813 |
| Did the plan have assets held for investment | 2021-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2021-12-31 | Disclaimer |
| Accountancy firm name | 2021-12-31 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2021-12-31 | 900189318 |
| 2020 : SPANSION COMPREHENSIVE WELFARE PLAN 2020 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2020-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $930,813 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $206,845 |
| Total income from all sources (including contributions) | 2020-12-31 | $29,322,177 |
| Total loss/gain on sale of assets | 2020-12-31 | $0 |
| Total of all expenses incurred | 2020-12-31 | $30,776,332 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-12-31 | $30,764,138 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-12-31 | $29,321,117 |
| Value of total assets at end of year | 2020-12-31 | $1,097,872 |
| Value of total assets at beginning of year | 2020-12-31 | $1,828,059 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-12-31 | $12,194 |
| Total interest from all sources | 2020-12-31 | $1,060 |
| Total dividends received (eg from common stock, registered investment company shares) | 2020-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-12-31 | No |
| Administrative expenses professional fees incurred | 2020-12-31 | $12,194 |
| Was this plan covered by a fidelity bond | 2020-12-31 | Yes |
| Value of fidelity bond cover | 2020-12-31 | $5,000,000 |
| If this is an individual account plan, was there a blackout period | 2020-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-12-31 | No |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2020-12-31 | $117,645 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2020-12-31 | $804,362 |
| Total non interest bearing cash at end of year | 2020-12-31 | $980,227 |
| Total non interest bearing cash at beginning of year | 2020-12-31 | $0 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Value of net income/loss | 2020-12-31 | $-1,454,155 |
| Value of net assets at end of year (total assets less liabilities) | 2020-12-31 | $167,059 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-12-31 | $1,621,214 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2020-12-31 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2020-12-31 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2020-12-31 | $0 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2020-12-31 | $1,023,697 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2020-12-31 | $1,023,697 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2020-12-31 | $1,060 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-12-31 | $10,177,244 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2020-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-12-31 | No |
| Contributions received in cash from employer | 2020-12-31 | $29,321,117 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-12-31 | $20,586,894 |
| Liabilities. Value of benefit claims payable at end of year | 2020-12-31 | $930,813 |
| Liabilities. Value of benefit claims payable at beginning of year | 2020-12-31 | $206,845 |
| Did the plan have assets held for investment | 2020-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2020-12-31 | Unqualified |
| Accountancy firm name | 2020-12-31 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2020-12-31 | 900189318 |
| 2019 : SPANSION COMPREHENSIVE WELFARE PLAN 2019 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2019-12-31 | $0 |
| Total unrealized appreciation/depreciation of assets | 2019-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $206,845 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $206,845 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $192,294 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $192,294 |
| Total income from all sources (including contributions) | 2019-12-31 | $32,382,332 |
| Total income from all sources (including contributions) | 2019-12-31 | $32,382,332 |
| Total loss/gain on sale of assets | 2019-12-31 | $0 |
| Total loss/gain on sale of assets | 2019-12-31 | $0 |
| Total of all expenses incurred | 2019-12-31 | $32,377,107 |
| Total of all expenses incurred | 2019-12-31 | $32,377,107 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $32,354,198 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $32,354,198 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $32,370,374 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $32,370,374 |
| Value of total assets at end of year | 2019-12-31 | $1,828,059 |
| Value of total assets at end of year | 2019-12-31 | $1,828,059 |
| Value of total assets at beginning of year | 2019-12-31 | $1,808,283 |
| Value of total assets at beginning of year | 2019-12-31 | $1,808,283 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $22,909 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $22,909 |
| Total interest from all sources | 2019-12-31 | $11,958 |
| Total interest from all sources | 2019-12-31 | $11,958 |
| Total dividends received (eg from common stock, registered investment company shares) | 2019-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2019-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | No |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | No |
| Was this plan covered by a fidelity bond | 2019-12-31 | Yes |
| Was this plan covered by a fidelity bond | 2019-12-31 | Yes |
| Value of fidelity bond cover | 2019-12-31 | $5,000,000 |
| Value of fidelity bond cover | 2019-12-31 | $5,000,000 |
| If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $804,362 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $804,362 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-12-31 | $485,812 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-12-31 | $485,812 |
| Administrative expenses (other) incurred | 2019-12-31 | $22,909 |
| Administrative expenses (other) incurred | 2019-12-31 | $22,909 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Value of net income/loss | 2019-12-31 | $5,225 |
| Value of net income/loss | 2019-12-31 | $5,225 |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $1,621,214 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $1,615,989 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $1,615,989 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2019-12-31 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2019-12-31 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2019-12-31 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2019-12-31 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2019-12-31 | $1,023,697 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2019-12-31 | $1,322,471 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2019-12-31 | $1,322,471 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2019-12-31 | $1,322,471 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2019-12-31 | $1,322,471 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2019-12-31 | $11,958 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $8,841,583 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $8,841,583 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | Yes |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Contributions received in cash from employer | 2019-12-31 | $32,370,374 |
| Contributions received in cash from employer | 2019-12-31 | $32,370,374 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2019-12-31 | $23,512,615 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2019-12-31 | $23,512,615 |
| Liabilities. Value of benefit claims payable at end of year | 2019-12-31 | $206,845 |
| Liabilities. Value of benefit claims payable at beginning of year | 2019-12-31 | $192,294 |
| Liabilities. Value of benefit claims payable at beginning of year | 2019-12-31 | $192,294 |
| Did the plan have assets held for investment | 2019-12-31 | Yes |
| Did the plan have assets held for investment | 2019-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | Yes |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Disclaimer |
| Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Disclaimer |
| Accountancy firm name | 2019-12-31 | MOSS ADAMS LLP |
| Accountancy firm name | 2019-12-31 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2019-12-31 | 900189318 |
| Accountancy firm EIN | 2019-12-31 | 900189318 |
| 2018 : SPANSION COMPREHENSIVE WELFARE PLAN 2018 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2018-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $192,294 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $252,402 |
| Total income from all sources (including contributions) | 2018-12-31 | $35,269,535 |
| Total loss/gain on sale of assets | 2018-12-31 | $0 |
| Total of all expenses incurred | 2018-12-31 | $35,167,516 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-12-31 | $35,144,935 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-12-31 | $35,257,804 |
| Value of total assets at end of year | 2018-12-31 | $1,808,283 |
| Value of total assets at beginning of year | 2018-12-31 | $1,766,372 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-12-31 | $22,581 |
| Total interest from all sources | 2018-12-31 | $11,384 |
| Total dividends received (eg from common stock, registered investment company shares) | 2018-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-12-31 | No |
| Was this plan covered by a fidelity bond | 2018-12-31 | Yes |
| Value of fidelity bond cover | 2018-12-31 | $5,000,000 |
| If this is an individual account plan, was there a blackout period | 2018-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2018-12-31 | No |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2018-12-31 | $485,812 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2018-12-31 | $241,968 |
| Administrative expenses (other) incurred | 2018-12-31 | $22,581 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Value of net income/loss | 2018-12-31 | $102,019 |
| Value of net assets at end of year (total assets less liabilities) | 2018-12-31 | $1,615,989 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-12-31 | $1,513,970 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2018-12-31 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2018-12-31 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2018-12-31 | $1,322,471 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2018-12-31 | $1,524,404 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2018-12-31 | $1,524,404 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2018-12-31 | $11,384 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-12-31 | $9,148,279 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2018-12-31 | $347 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2018-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-12-31 | No |
| Contributions received in cash from employer | 2018-12-31 | $35,257,804 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2018-12-31 | $25,996,656 |
| Liabilities. Value of benefit claims payable at end of year | 2018-12-31 | $192,294 |
| Liabilities. Value of benefit claims payable at beginning of year | 2018-12-31 | $252,402 |
| Did the plan have assets held for investment | 2018-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2018-12-31 | Disclaimer |
| Accountancy firm name | 2018-12-31 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2018-12-31 | 900189318 |
| 2017 : SPANSION COMPREHENSIVE WELFARE PLAN 2017 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2017-12-31 | $0 |
| Total transfer of assets to this plan | 2017-12-31 | $1,133,144 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $252,402 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $651,321 |
| Total income from all sources (including contributions) | 2017-12-31 | $33,659,582 |
| Total loss/gain on sale of assets | 2017-12-31 | $0 |
| Total of all expenses incurred | 2017-12-31 | $33,847,657 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-12-31 | $33,824,938 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-12-31 | $33,643,958 |
| Value of total assets at end of year | 2017-12-31 | $1,766,372 |
| Value of total assets at beginning of year | 2017-12-31 | $1,220,222 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-12-31 | $22,719 |
| Total interest from all sources | 2017-12-31 | $7,019 |
| Total dividends received (eg from common stock, registered investment company shares) | 2017-12-31 | $1,011 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2017-12-31 | $1,011 |
| Was this plan covered by a fidelity bond | 2017-12-31 | Yes |
| Value of fidelity bond cover | 2017-12-31 | $5,000,000 |
| If this is an individual account plan, was there a blackout period | 2017-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | No |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2017-12-31 | $-398,919 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2017-12-31 | $241,968 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2017-12-31 | $719,301 |
| Administrative expenses (other) incurred | 2017-12-31 | $22,719 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Value of net income/loss | 2017-12-31 | $-188,075 |
| Value of net assets at end of year (total assets less liabilities) | 2017-12-31 | $1,513,970 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-12-31 | $568,901 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2017-12-31 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2017-12-31 | $337,126 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2017-12-31 | $1,524,404 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2017-12-31 | $163,795 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2017-12-31 | $163,795 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2017-12-31 | $7,019 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-12-31 | $9,383,914 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2017-12-31 | $7,594 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Contributions received in cash from employer | 2017-12-31 | $33,643,958 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2017-12-31 | $24,839,943 |
| Liabilities. Value of benefit claims payable at end of year | 2017-12-31 | $252,402 |
| Liabilities. Value of benefit claims payable at beginning of year | 2017-12-31 | $651,321 |
| Did the plan have assets held for investment | 2017-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2017-12-31 | Disclaimer |
| Accountancy firm name | 2017-12-31 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2017-12-31 | 900189318 |
| 2016 : SPANSION COMPREHENSIVE WELFARE PLAN 2016 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2016-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $651,321 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $673,224 |
| Total income from all sources (including contributions) | 2016-12-31 | $30,431,464 |
| Total loss/gain on sale of assets | 2016-12-31 | $0 |
| Total of all expenses incurred | 2016-12-31 | $29,804,881 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-12-31 | $29,779,716 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-12-31 | $30,420,862 |
| Value of total assets at end of year | 2016-12-31 | $1,220,222 |
| Value of total assets at beginning of year | 2016-12-31 | $615,542 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-12-31 | $25,165 |
| Total interest from all sources | 2016-12-31 | $903 |
| Total dividends received (eg from common stock, registered investment company shares) | 2016-12-31 | $8,940 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2016-12-31 | $8,940 |
| Was this plan covered by a fidelity bond | 2016-12-31 | Yes |
| Value of fidelity bond cover | 2016-12-31 | $5,000,000 |
| If this is an individual account plan, was there a blackout period | 2016-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-12-31 | No |
| Contributions received from participants | 2016-12-31 | $78,825 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2016-12-31 | $-21,903 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2016-12-31 | $719,301 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2016-12-31 | $104,915 |
| Administrative expenses (other) incurred | 2016-12-31 | $25,165 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Value of net income/loss | 2016-12-31 | $626,583 |
| Value of net assets at end of year (total assets less liabilities) | 2016-12-31 | $568,901 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-12-31 | $-57,682 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2016-12-31 | $337,126 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2016-12-31 | $336,365 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2016-12-31 | $163,795 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2016-12-31 | $174,262 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2016-12-31 | $174,262 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2016-12-31 | $903 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-12-31 | $9,942,622 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2016-12-31 | $759 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2016-12-31 | Yes |
| Has the plan failed to provide any benefit when due under the plan | 2016-12-31 | No |
| Contributions received in cash from employer | 2016-12-31 | $30,342,037 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2016-12-31 | $19,858,997 |
| Liabilities. Value of benefit claims payable at end of year | 2016-12-31 | $651,321 |
| Liabilities. Value of benefit claims payable at beginning of year | 2016-12-31 | $673,224 |
| Did the plan have assets held for investment | 2016-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2016-12-31 | Disclaimer |
| Accountancy firm name | 2016-12-31 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2016-12-31 | 900189318 |
| 2015 : SPANSION COMPREHENSIVE WELFARE PLAN 2015 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2015-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $673,224 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $375,054 |
| Total income from all sources (including contributions) | 2015-12-31 | $20,463,143 |
| Total loss/gain on sale of assets | 2015-12-31 | $0 |
| Total of all expenses incurred | 2015-12-31 | $21,274,302 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-12-31 | $21,248,026 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-12-31 | $20,454,366 |
| Value of total assets at end of year | 2015-12-31 | $615,542 |
| Value of total assets at beginning of year | 2015-12-31 | $1,128,531 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-12-31 | $26,276 |
| Total interest from all sources | 2015-12-31 | $35 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-12-31 | $11,977 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2015-12-31 | $11,977 |
| Was this plan covered by a fidelity bond | 2015-12-31 | Yes |
| Value of fidelity bond cover | 2015-12-31 | $5,000,000 |
| If this is an individual account plan, was there a blackout period | 2015-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Contributions received from participants | 2015-12-31 | $112,650 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2015-12-31 | $298,170 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2015-12-31 | $104,915 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2015-12-31 | $234,112 |
| Administrative expenses (other) incurred | 2015-12-31 | $26,276 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net income/loss | 2015-12-31 | $-811,159 |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $-57,682 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-12-31 | $753,477 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2015-12-31 | $336,365 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2015-12-31 | $730,923 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2015-12-31 | $174,262 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2015-12-31 | $163,496 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2015-12-31 | $163,496 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2015-12-31 | $35 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-12-31 | $5,269,841 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2015-12-31 | $-3,235 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | Yes |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Contributions received in cash from employer | 2015-12-31 | $20,341,716 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-12-31 | $15,680,015 |
| Liabilities. Value of benefit claims payable at end of year | 2015-12-31 | $673,224 |
| Liabilities. Value of benefit claims payable at beginning of year | 2015-12-31 | $375,054 |
| Did the plan have assets held for investment | 2015-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2015-12-31 | Disclaimer |
| Accountancy firm name | 2015-12-31 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2015-12-31 | 910189318 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 602161 |
| Policy instance | 13 |
| Insurance contract or identification number | 602161 | | Number of Individuals Covered | 627 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,585 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $3,098,965 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,585 | | Insurance broker organization code? | 3 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9907-5742 |
| Policy instance | 1 |
| Insurance contract or identification number | 9907-5742 | | Number of Individuals Covered | 1803 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 $0 | | 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 | 805897G |
| Policy instance | 2 |
| Insurance contract or identification number | 805897G | | Number of Individuals Covered | 2638 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | Yes | | 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 $167,474 | | 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 | 0162445 |
| Policy instance | 3 |
| Insurance contract or identification number | 0162445 | | Number of Individuals Covered | 2730 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $114,923 | | Total amount of fees paid to insurance company | USD $1,132 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 $966,499 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,071 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 53 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | PAI0009118077-C |
| Policy instance | 4 |
| Insurance contract or identification number | PAI0009118077-C | | Number of Individuals Covered | 1803 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 $96,202 | | 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 | 0480602 |
| Policy instance | 5 |
| Insurance contract or identification number | 0480602 | | Number of Individuals Covered | 2632 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $22,132 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | Yes | | 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 $387,428 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,132 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 921523 |
| Policy instance | 6 |
| Insurance contract or identification number | 921523 | | Number of Individuals Covered | 1254 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $259,636 | | Total amount of fees paid to insurance company | USD $107,588 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | | 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 $2,354,164 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $259,636 | | Amount paid for insurance broker fees | 107588 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 ) |
| Policy contract number | 1030 |
| Policy instance | 7 |
| Insurance contract or identification number | 1030 | | Number of Individuals Covered | 1580 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $39,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 571019 |
| Policy instance | 8 |
| Insurance contract or identification number | 571019 | | Number of Individuals Covered | 591 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | PRE-PAID LEGAL | | 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 $102,097 | | 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 | 22047 |
| Policy instance | 9 |
| Insurance contract or identification number | 22047 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $307 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $49,336 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $307 | | Insurance broker organization code? | 3 |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 1908700 |
| Policy instance | 10 |
| Insurance contract or identification number | 1908700 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $115,401 | | 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 | 233168 |
| Policy instance | 11 |
| Insurance contract or identification number | 233168 | | Number of Individuals Covered | 42 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $525 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $186,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $525 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 9347 |
| Policy instance | 12 |
| Insurance contract or identification number | 9347 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,001 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $372,731 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,001 | | Insurance broker organization code? | 3 |
|
| CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 ) |
| Policy contract number | 1030 |
| Policy instance | 8 |
| Insurance contract or identification number | 1030 | | Number of Individuals Covered | 1797 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,517 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $35,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,517 | | Insurance broker organization code? | 3 |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 571019 |
| Policy instance | 9 |
| Insurance contract or identification number | 571019 | | Number of Individuals Covered | 613 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $12,757 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | PRE-PAID LEGAL | | 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 $117,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,437 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 22047 |
| Policy instance | 10 |
| Insurance contract or identification number | 22047 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,957 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $65,287 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,957 | | Insurance broker organization code? | 3 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9907-5742 |
| Policy instance | 11 |
| Insurance contract or identification number | 9907-5742 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $-27 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 $-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 $-27 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0162445 |
| Policy instance | 12 |
| Insurance contract or identification number | 0162445 | | Number of Individuals Covered | 2829 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $94,780 | | Total amount of fees paid to insurance company | USD $178 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,042,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $94,780 | | Amount paid for insurance broker fees | 178 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 602161 |
| Policy instance | 7 |
| Insurance contract or identification number | 602161 | | Number of Individuals Covered | 610 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $89,405 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $2,963,002 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $89,405 | | Insurance broker organization code? | 3 |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | PAI0009118077-C |
| Policy instance | 6 |
| Insurance contract or identification number | PAI0009118077-C | | Number of Individuals Covered | 1804 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $17,571 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT; PARALYSIS | | 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 $117,142 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,571 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 921523 |
| Policy instance | 1 |
| Insurance contract or identification number | 921523 | | Number of Individuals Covered | 1389 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,769,036 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 190870 |
| Policy instance | 2 |
| Insurance contract or identification number | 190870 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $35,497 | | 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 | 0480602 |
| Policy instance | 3 |
| Insurance contract or identification number | 0480602 | | Number of Individuals Covered | 4531 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $34,715 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | Yes | | 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 $679,735 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,715 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 233168 |
| Policy instance | 4 |
| Insurance contract or identification number | 233168 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,475 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $179,487 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,475 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 9347 |
| Policy instance | 5 |
| Insurance contract or identification number | 9347 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,842 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $388,940 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,842 | | Insurance broker organization code? | 3 |
|
| CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 ) |
| Policy contract number | 1030 |
| Policy instance | 10 |
| Insurance contract or identification number | 1030 | | Number of Individuals Covered | 1861 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,339 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $43,391 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,339 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0480602 |
| Policy instance | 9 |
| Insurance contract or identification number | 0480602 | | Number of Individuals Covered | 4554 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $41,894 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | Yes | | 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 $869,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,894 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 233168 |
| Policy instance | 8 |
| Insurance contract or identification number | 233168 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $6,918 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $233,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,918 | | Insurance broker organization code? | 3 |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | PAI0009118077-B |
| Policy instance | 7 |
| Insurance contract or identification number | PAI0009118077-B | | Number of Individuals Covered | 1126 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $6,000 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT; PARALYSIS | | 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 $119,995 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,000 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 602161 |
| Policy instance | 6 |
| Insurance contract or identification number | 602161 | | Number of Individuals Covered | 648 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $101,932 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $3,533,959 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $101,932 | | Insurance broker organization code? | 3 |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 70484-9 |
| Policy instance | 5 |
| Insurance contract or identification number | 70484-9 | | Number of Individuals Covered | 1459 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $36,479 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,823,939 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,479 | | Insurance broker organization code? | 3 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9907-5742 |
| Policy instance | 4 |
| Insurance contract or identification number | 9907-5742 | | Number of Individuals Covered | 6031 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $20,705 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 $138,035 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,705 | | Insurance broker organization code? | 3 |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 571019 |
| Policy instance | 3 |
| Insurance contract or identification number | 571019 | | Number of Individuals Covered | 618 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $12,990 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | PRE-PAID LEGAL | | 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 $129,591 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,990 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 9347 |
| Policy instance | 2 |
| Insurance contract or identification number | 9347 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,331 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $488,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,331 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0162445 |
| Policy instance | 1 |
| Insurance contract or identification number | 0162445 | | Number of Individuals Covered | 2923 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $105,003 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,038,269 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $105,003 | | Insurance broker organization code? | 3 |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 571019 |
| Policy instance | 6 |
| Insurance contract or identification number | 571019 | | Number of Individuals Covered | 595 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $12,032 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | PRE-PAID LEGAL | | 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 $120,869 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,032 | | Insurance broker organization code? | 3 | | Insurance broker name | INNOVATIVE COST MANAGEMENT SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 233168 |
| Policy instance | 5 |
| Insurance contract or identification number | 233168 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $6,059 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $212,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,059 | | Insurance broker organization code? | 3 | | Insurance broker name | INNOVATIVE COST MANAGEMENT SERVICES |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | PAI0009118077-B |
| Policy instance | 4 |
| Insurance contract or identification number | PAI0009118077-B | | Number of Individuals Covered | 1153 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $5,417 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT; PARALYSIS | | 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 $108,346 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,417 | | Insurance broker organization code? | 3 | | Insurance broker name | INNOVATIVE COST MANAGEMENT SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 9347 |
| Policy instance | 3 |
| Insurance contract or identification number | 9347 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $10,714 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $357,128 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,714 | | Insurance broker organization code? | 3 | | Insurance broker name | INNOVATIVE COST MANAGEMENT SERVICES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | 02615A |
| Policy instance | 2 |
| Insurance contract or identification number | 02615A | | Number of Individuals Covered | 55 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 $27,219 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02615A |
| Policy instance | 7 |
| Insurance contract or identification number | 02615A | | Number of Individuals Covered | 55 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM; AND EVACUATION | | 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 $234,878 | | 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 | 0480602 |
| Policy instance | 8 |
| Insurance contract or identification number | 0480602 | | Number of Individuals Covered | 4705 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $50,755 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | Yes | | 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 $962,863 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50,755 | | Insurance broker organization code? | 3 | | Insurance broker name | INNOVATIVE COST MANAGEMENT SERVICES |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9907-57-42 |
| Policy instance | 9 |
| Insurance contract or identification number | 9907-57-42 | | Number of Individuals Covered | 6388 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-04-30 | | Total amount of commissions paid to insurance broker | USD $4,883 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 $32,552 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,883 | | Insurance broker organization code? | 3 | | Insurance broker name | INNOVATIVE COST MANAGEMENT SERVICES |
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| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9907-57-42 |
| Policy instance | 10 |
| Insurance contract or identification number | 9907-57-42 | | Number of Individuals Covered | 6435 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $624 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 $4,158 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $624 | | Insurance broker organization code? | 3 | | Insurance broker name | INNOVATIVE COST MANAGEMENT SERVICES |
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| CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 ) |
| Policy contract number | 1030 |
| Policy instance | 11 |
| Insurance contract or identification number | 1030 | | Number of Individuals Covered | 2056 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $4,124 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $41,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,124 | | Insurance broker organization code? | 3 | | Insurance broker name | INNOVATIVE COST MANAGEMENT SERVICES |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 602161 |
| Policy instance | 12 |
| Insurance contract or identification number | 602161 | | Number of Individuals Covered | 680 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $104,617 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 $3,509,772 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $104,617 | | Insurance broker organization code? | 3 | | Insurance broker name | INNOVATIVE COST MANAGEMENT SERVICES |
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 239571 |
| Policy instance | 13 |
| Insurance contract or identification number | 239571 | | Number of Individuals Covered | 1571 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $195,955 | | Total amount of fees paid to insurance company | USD $97,978 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,785,696 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $195,955 | | Amount paid for insurance broker fees | 97978 | | Additional information about fees paid to insurance broker | OVERRIDE COMMISSIONS BONUS COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | ALTERNATIVE RISK SOLUTIONS LLC |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0162445 |
| Policy instance | 1 |
| Insurance contract or identification number | 0162445 | | Number of Individuals Covered | 3109 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $97,726 | | Total amount of fees paid to insurance company | USD $129 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 $982,242 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $97,726 | | Amount paid for insurance broker fees | 129 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | INNOVATIVE COST MANAGEMENT SERVICES |
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