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J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 401k Plan overview

Plan NameJ.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN
Plan identification number 501

J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

JS INTERNATIONAL CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:JS INTERNATIONAL CORPORATION
Employer identification number (EIN):943058163
NAIC Classification:488510
NAIC Description:Freight Transportation Arrangement

Additional information about JS INTERNATIONAL CORPORATION

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: C3688732

More information about JS INTERNATIONAL CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012018-10-01
5012017-10-01
5012017-10-01MAGGIE CHEN2019-05-24
5012016-10-01TERENCE GRIFFIN
5012015-10-01MAGGIE CHEN
5012013-10-01ALISSA TRAN ALISSA TRAN2015-04-13
5012012-10-01ALISSA TRAN ALISSA TRAN2014-04-29
5012011-10-01ALISSA TRAN
5012009-10-01ALISSA TRAN

Plan Statistics for J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN

401k plan membership statisitcs for J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN

Measure Date Value
2018: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-10-01145
Total number of active participants reported on line 7a of the Form 55002018-10-010
Number of retired or separated participants receiving benefits2018-10-010
Number of other retired or separated participants entitled to future benefits2018-10-010
Total of all active and inactive participants2018-10-010
Number of employers contributing to the scheme2018-10-010
2017: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-10-01133
Total number of active participants reported on line 7a of the Form 55002017-10-01144
Number of retired or separated participants receiving benefits2017-10-011
Number of other retired or separated participants entitled to future benefits2017-10-019
Total of all active and inactive participants2017-10-01154
Number of employers contributing to the scheme2017-10-010
2016: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01161
Total number of active participants reported on line 7a of the Form 55002016-10-01131
Number of retired or separated participants receiving benefits2016-10-012
Number of other retired or separated participants entitled to future benefits2016-10-010
Total of all active and inactive participants2016-10-01133
2015: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01153
Total number of active participants reported on line 7a of the Form 55002015-10-01158
Number of retired or separated participants receiving benefits2015-10-013
Number of other retired or separated participants entitled to future benefits2015-10-010
Total of all active and inactive participants2015-10-01161
2013: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-10-01165
Total number of active participants reported on line 7a of the Form 55002013-10-01138
Number of retired or separated participants receiving benefits2013-10-013
Number of other retired or separated participants entitled to future benefits2013-10-010
Total of all active and inactive participants2013-10-01141
2012: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-10-01149
Total number of active participants reported on line 7a of the Form 55002012-10-01162
Number of retired or separated participants receiving benefits2012-10-013
Number of other retired or separated participants entitled to future benefits2012-10-010
Total of all active and inactive participants2012-10-01165
2011: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-10-01126
Total number of active participants reported on line 7a of the Form 55002011-10-01149
Number of retired or separated participants receiving benefits2011-10-010
Number of other retired or separated participants entitled to future benefits2011-10-010
Total of all active and inactive participants2011-10-01149
2009: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-10-01108
Total number of active participants reported on line 7a of the Form 55002009-10-01112
Number of retired or separated participants receiving benefits2009-10-012
Number of other retired or separated participants entitled to future benefits2009-10-010
Total of all active and inactive participants2009-10-01114

Form 5500 Responses for J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN

2018: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01This submission is the final filingYes
2018-10-01This return/report is a short plan year return/report (less than 12 months)Yes
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – InsuranceYes
2017: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Submission has been amendedYes
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – InsuranceYes
2016: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)No
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – InsuranceYes
2015: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – InsuranceYes
2013: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-10-01Type of plan entitySingle employer plan
2013-10-01Submission has been amendedNo
2013-10-01This submission is the final filingNo
2013-10-01This return/report is a short plan year return/report (less than 12 months)No
2013-10-01Plan is a collectively bargained planNo
2013-10-01Plan funding arrangement – InsuranceYes
2013-10-01Plan benefit arrangement – InsuranceYes
2012: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-10-01Type of plan entitySingle employer plan
2012-10-01Submission has been amendedNo
2012-10-01This submission is the final filingNo
2012-10-01This return/report is a short plan year return/report (less than 12 months)No
2012-10-01Plan is a collectively bargained planNo
2012-10-01Plan funding arrangement – InsuranceYes
2012-10-01Plan benefit arrangement – InsuranceYes
2011: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-10-01Type of plan entitySingle employer plan
2011-10-01Submission has been amendedNo
2011-10-01This submission is the final filingNo
2011-10-01This return/report is a short plan year return/report (less than 12 months)No
2011-10-01Plan is a collectively bargained planNo
2011-10-01Plan funding arrangement – InsuranceYes
2011-10-01Plan benefit arrangement – InsuranceYes
2009: J.S. INTERNATIONAL CORPORATION WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-10-01Type of plan entitySingle employer plan
2009-10-01Submission has been amendedNo
2009-10-01This submission is the final filingNo
2009-10-01This return/report is a short plan year return/report (less than 12 months)No
2009-10-01Plan is a collectively bargained planNo
2009-10-01Plan funding arrangement – InsuranceYes
2009-10-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AXSN
Policy instance 7
Insurance contract or identification numberGLUG0AXSN
Number of Individuals Covered133
Insurance policy start date2018-10-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,864
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $18,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,249
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number0805777HNO
Policy instance 1
Insurance contract or identification number0805777HNO
Number of Individuals Covered70
Insurance policy start date2018-10-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $8,264
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $134,316
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,956
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number921778-000
Policy instance 6
Insurance contract or identification number921778-000
Number of Individuals Covered261
Insurance policy start date2018-08-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $8,588
Total amount of fees paid to insurance companyUSD $908
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $5,182
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30035774
Policy instance 5
Insurance contract or identification number30035774
Number of Individuals Covered126
Insurance policy start date2018-10-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $452
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $302
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number39174
Policy instance 4
Insurance contract or identification number39174
Number of Individuals Covered30
Insurance policy start date2018-10-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,446
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,727
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0805777
Policy instance 2
Insurance contract or identification number0805777
Number of Individuals Covered87
Insurance policy start date2018-10-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $10,324
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $178,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,576
Amount paid for insurance broker fees0
Insurance broker organization code?3
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number018883
Policy instance 3
Insurance contract or identification number018883
Number of Individuals Covered21
Insurance policy start date2018-10-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,253
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $41,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $826
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AXSN
Policy instance 7
Insurance contract or identification numberGLUG0AXSN
Number of Individuals Covered144
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $7,359
Total amount of fees paid to insurance companyUSD $2,817
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $73,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number084404
Policy instance 6
Insurance contract or identification number084404
Number of Individuals Covered37
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $7,552
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $328,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number921093-000
Policy instance 5
Insurance contract or identification number921093-000
Number of Individuals Covered269
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $18,783
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $125,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number0805777HNO
Policy instance 1
Insurance contract or identification number0805777HNO
Number of Individuals Covered69
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $28,128
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $438,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number39174
Policy instance 3
Insurance contract or identification number39174
Number of Individuals Covered40
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $11,431
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $203,105
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 number0805777
Policy instance 2
Insurance contract or identification number0805777
Number of Individuals Covered92
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $45,757
Total amount of fees paid to insurance companyUSD $62
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $694,468
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30035774
Policy instance 4
Insurance contract or identification number30035774
Number of Individuals Covered131
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $1,835
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AXSN
Policy instance 7
Insurance contract or identification numberGVTL0AXSN
Number of Individuals Covered42
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $2,467
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $24,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,467
Insurance broker organization code?3
Insurance broker nameEDGEWOOD PARTNERS INSURANCE CENTER
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number0805777HNO
Policy instance 6
Insurance contract or identification number0805777HNO
Number of Individuals Covered64
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $30,655
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $464,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,581
Insurance broker organization code?3
Insurance broker nameROGERS BENEFIT GROUP INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30035774
Policy instance 5
Insurance contract or identification number30035774
Number of Individuals Covered123
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $985
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $16,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $985
Insurance broker organization code?3
Insurance broker nameEDGEWOOD PARTNERS INSURANCE CENTER
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number39174
Policy instance 4
Insurance contract or identification number39174
Number of Individuals Covered47
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $13,684
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $296,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,684
Insurance broker organization code?3
Insurance broker nameEDGEWOOD PARTNERS INSURANCE CENTER
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AXSN
Policy instance 3
Insurance contract or identification numberGLUG0AXSN
Number of Individuals Covered138
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $343
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $3,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $343
Insurance broker organization code?3
Insurance broker nameEDGEWOOD PARTNERS INSURANCE CENTER
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0805777
Policy instance 2
Insurance contract or identification number0805777
Number of Individuals Covered245
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $49,692
Total amount of fees paid to insurance companyUSD $3,968
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $652,373
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,667
Amount paid for insurance broker fees3968
Additional information about fees paid to insurance brokerPM CROSS SALE PPP ENGAGEMENT CREDIT
Insurance broker organization code?3
Insurance broker nameROGERS BENEFIT GROUP INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AXSN
Policy instance 1
Insurance contract or identification numberGLTD0AXSN
Number of Individuals Covered138
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $1,394
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $13,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,394
Insurance broker organization code?3
Insurance broker nameEDGEWOOD PARTNERS INSURANCE CENTER
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000T86U
Policy instance 1
Insurance contract or identification numberG000T86U
Number of Individuals Covered138
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $7,119
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $49,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,119
Insurance broker organization code?3
Insurance broker nameJENKINS INSURANCE SERVICES
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0805777
Policy instance 2
Insurance contract or identification number0805777
Number of Individuals Covered76
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $37,153
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $532,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,579
Insurance broker organization code?3
Insurance broker nameROGERS BENEFIT GROUP INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30035774
Policy instance 3
Insurance contract or identification number30035774
Number of Individuals Covered138
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $1,167
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $22,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,167
Insurance broker organization code?3
Insurance broker nameJENKINS INSURANCE SERVICES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number39174
Policy instance 4
Insurance contract or identification number39174
Number of Individuals Covered48
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $12,791
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $277,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,791
Insurance broker organization code?3
Insurance broker nameJENKINS INSURANCE SERVICES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05995109
Policy instance 6
Insurance contract or identification numberKM05995109
Number of Individuals Covered141
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $4,204
Total amount of fees paid to insurance companyUSD $331
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $143,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,204
Amount paid for insurance broker fees331
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameJENKINS INSURANCE SERVICES
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number0805777HNO
Policy instance 5
Insurance contract or identification number0805777HNO
Number of Individuals Covered90
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $30,468
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $509,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,437
Insurance broker organization code?3
Insurance broker nameROGERS BENEFIT GROUP INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number39174
Policy instance 2
Insurance contract or identification number39174
Number of Individuals Covered40
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $11,066
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $221,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,066
Insurance broker organization code?3
Insurance broker nameJENKINS INSURANCE SERVICES
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number805777
Policy instance 3
Insurance contract or identification number805777
Number of Individuals Covered83
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $26,241
Total amount of fees paid to insurance companyUSD $15,060
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $478,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,241
Amount paid for insurance broker fees15060
Additional information about fees paid to insurance broker2012 MEDICAL NEW SALES SUPPLEMENTAL COMPENSATION 2012 NEW BUSINESS BONUS
Insurance broker organization code?3
Insurance broker nameJENKINS INSURANCE SERVICES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05995109
Policy instance 4
Insurance contract or identification numberKM05995109
Number of Individuals Covered397
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $3,641
Total amount of fees paid to insurance companyUSD $3,371
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $123,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,641
Amount paid for insurance broker fees3371
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameJENKINS INSURANCE SERVICES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000T86U
Policy instance 5
Insurance contract or identification numberG000T86U
Number of Individuals Covered161
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $7,312
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $50,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,312
Insurance broker organization code?3
Insurance broker nameJENKINS INSURANCE SERVICES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30035774
Policy instance 1
Insurance contract or identification number30035774
Number of Individuals Covered140
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $1,097
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $19,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,097
Insurance broker organization code?3
Insurance broker nameJENKINS INSURANCE SERVICES
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberUS456497
Policy instance 6
Insurance contract or identification numberUS456497
Number of Individuals Covered101
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $22,131
Total amount of fees paid to insurance companyUSD $3,130
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $411,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,131
Amount paid for insurance broker fees3130
Additional information about fees paid to insurance broker2012 MEDICAL NEW SALES SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameJENKINS INSURANCE SERVICES
PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )
Policy contract number11680
Policy instance 3
Insurance contract or identification number11680
Number of Individuals Covered120
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $4,313
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $121,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000T86U
Policy instance 4
Insurance contract or identification numberG000T86U
Number of Individuals Covered149
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $6,685
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $45,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN5487/15869
Policy instance 1
Insurance contract or identification numberN5487/15869
Number of Individuals Covered119
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $44,242
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $867,025
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 number39174
Policy instance 2
Insurance contract or identification number39174
Number of Individuals Covered20
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $10,029
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $200,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )
Policy contract number11680
Policy instance 1
Insurance contract or identification number11680
Number of Individuals Covered115
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $3,976
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $110,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberN5487/15869
Policy instance 4
Insurance contract or identification numberN5487/15869
Number of Individuals Covered114
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $40,870
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $823,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000T86U
Policy instance 5
Insurance contract or identification numberG000T86U
Number of Individuals Covered126
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $6,717
Total amount of fees paid to insurance companyUSD $670
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $43,546
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 number39174
Policy instance 3
Insurance contract or identification number39174
Number of Individuals Covered18
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $8,155
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $137,386
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 number13903
Policy instance 2
Insurance contract or identification number13903
Number of Individuals Covered1
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $3,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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