BAY AREA TECHWORKERS has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2020: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 126 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 99 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 99 |
| Number of employers contributing to the scheme | 2020-10-01 | 0 |
| 2019: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 139 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 126 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 126 |
| Number of employers contributing to the scheme | 2019-10-01 | 0 |
| 2018: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 161 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 139 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 139 |
| Number of employers contributing to the scheme | 2018-10-01 | 0 |
| 2017: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 161 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 161 |
| Number of employers contributing to the scheme | 2017-10-01 | 0 |
| 2016: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 128 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 118 |
| Number of retired or separated participants receiving benefits | 2016-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
| Total of all active and inactive participants | 2016-10-01 | 118 |
| 2015: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 128 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
| Total of all active and inactive participants | 2015-10-01 | 128 |
| 2014: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 112 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2014-10-01 | 0 |
| Total of all active and inactive participants | 2014-10-01 | 118 |
| 2013: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 147 |
| Number of retired or separated participants receiving benefits | 2013-10-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2013-10-01 | 0 |
| Total of all active and inactive participants | 2013-10-01 | 152 |
| 2020: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Submission has been amended | Yes |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Submission has been amended | No |
| 2016-10-01 | This submission is the final filing | No |
| 2016-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-10-01 | Plan is a collectively bargained plan | No |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Submission has been amended | No |
| 2015-10-01 | This submission is the final filing | No |
| 2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-10-01 | Plan is a collectively bargained plan | No |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Submission has been amended | No |
| 2014-10-01 | This submission is the final filing | No |
| 2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-10-01 | Plan is a collectively bargained plan | No |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: BAY AREA TECHWORKERS HEALTH AND WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | First time form 5500 has been submitted | Yes |
| 2013-10-01 | Submission has been amended | No |
| 2013-10-01 | This submission is the final filing | No |
| 2013-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-10-01 | Plan is a collectively bargained plan | No |
| 2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | W0054326 |
| Policy instance | 6 |
| Insurance contract or identification number | W0054326 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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? | Yes | | Commission paid to Insurance Broker | USD $291 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0054326 |
| Policy instance | 5 |
| Insurance contract or identification number | W0054326 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 10974 | | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30060201 |
| Policy instance | 4 |
| Insurance contract or identification number | 30060201 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $484 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 9225 |
| Policy instance | 3 |
| Insurance contract or identification number | 9225 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5930643 |
| Policy instance | 2 |
| Insurance contract or identification number | 5930643 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,702 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 604901 |
| Policy instance | 1 |
| Insurance contract or identification number | 604901 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,236 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 604901 |
| Policy instance | 1 |
| Insurance contract or identification number | 604901 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $10,988 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $217,948 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,988 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5930643 |
| Policy instance | 2 |
| Insurance contract or identification number | 5930643 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $6,870 | | Total amount of fees paid to insurance company | USD $1,456 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $67,880 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,870 | | Amount paid for insurance broker fees | 1456 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 9225 |
| Policy instance | 3 |
| Insurance contract or identification number | 9225 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,278 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30060201 |
| Policy instance | 4 |
| Insurance contract or identification number | 30060201 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $831 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,251 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $831 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0054326 |
| Policy instance | 5 |
| Insurance contract or identification number | W0054326 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $21,933 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $407,092 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 21933 | | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | W0054326 |
| Policy instance | 6 |
| Insurance contract or identification number | W0054326 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $480 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $9,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $480 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | W0054326 |
| Policy instance | 6 |
| Insurance contract or identification number | W0054326 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $559 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $11,170 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $559 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0054326 |
| Policy instance | 5 |
| Insurance contract or identification number | W0054326 | | Number of Individuals Covered | 105 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $25,514 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $485,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 25514 | | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEE | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30060201 |
| Policy instance | 4 |
| Insurance contract or identification number | 30060201 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $700 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,038 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $700 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 9225 |
| Policy instance | 3 |
| Insurance contract or identification number | 9225 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,171 | | 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 | 5930643 |
| Policy instance | 2 |
| Insurance contract or identification number | 5930643 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $6,904 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $75,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,904 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 604901 |
| Policy instance | 1 |
| Insurance contract or identification number | 604901 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $10,211 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $203,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,211 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | W0054326 |
| Policy instance | 6 |
| Insurance contract or identification number | W0054326 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $662 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $13,241 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0054326 |
| Policy instance | 5 |
| Insurance contract or identification number | W0054326 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $26,565 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $531,300 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30060201 |
| Policy instance | 4 |
| Insurance contract or identification number | 30060201 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $786 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,014 | | 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 | 9225 |
| Policy instance | 3 |
| Insurance contract or identification number | 9225 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,094 | | 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 | KM05930643 |
| Policy instance | 2 |
| Insurance contract or identification number | KM05930643 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $10,418 | | Total amount of fees paid to insurance company | USD $256 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $93,327 | | 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 | 604901 |
| Policy instance | 1 |
| Insurance contract or identification number | 604901 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $15,969 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $292,459 | | 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 | KM05930643 |
| Policy instance | 1 |
| Insurance contract or identification number | KM05930643 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $10,421 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | 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 | | 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 $113,025 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,421 | | Insurance broker organization code? | 3 | | Insurance broker name | ANDREINI AND COMPANY |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | W0054326 |
| Policy instance | 2 |
| Insurance contract or identification number | W0054326 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $1,006 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND 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 $20,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,006 | | Insurance broker organization code? | 3 | | Insurance broker name | ANDREINI AND COMPANY |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 604901 |
| Policy instance | 3 |
| Insurance contract or identification number | 604901 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $17,644 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $382,256 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,644 | | Insurance broker organization code? | 3 | | Insurance broker name | ANDREINI AND COMPANY |
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| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0054326 |
| Policy instance | 4 |
| Insurance contract or identification number | W0054326 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $26,879 | | Total amount of fees paid to insurance company | USD $8,245 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $537,572 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,879 | | Amount paid for insurance broker fees | 8245 | | Additional information about fees paid to insurance broker | BONUS OVERRIDE ALLOCATION | | Insurance broker organization code? | 3 | | Insurance broker name | ANDREINI AND COMPANY |
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 902048 |
| Policy instance | 5 |
| Insurance contract or identification number | 902048 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $202 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30060201 |
| Policy instance | 6 |
| Insurance contract or identification number | 30060201 | | Number of Individuals Covered | 85 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $885 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,781 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $885 | | Insurance broker organization code? | 3 | | Insurance broker name | ANDREINI AND COMPANY |
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| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 663326 |
| Policy instance | 3 |
| Insurance contract or identification number | 663326 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $5,159 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $123,531 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,159 | | Insurance broker organization code? | 3 | | Insurance broker name | ANDREINI & COMPANY |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 97629 |
| Policy instance | 2 |
| Insurance contract or identification number | 97629 | | Number of Individuals Covered | 84 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $16,953 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $313,504 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,953 | | Insurance broker organization code? | 3 | | Insurance broker name | ANDREINI & COMPANY |
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| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 379475 |
| Policy instance | 1 |
| Insurance contract or identification number | 379475 | | Number of Individuals Covered | 69 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $38,759 | | Total amount of fees paid to insurance company | USD $29,619 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $583,921 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,759 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 29619 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker name | LISI, INC. |
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| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 379475 |
| Policy instance | 3 |
| Insurance contract or identification number | 379475 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $38,283 | | Total amount of fees paid to insurance company | USD $19,115 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $574,157 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,283 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 19115 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker name | LISI, INC. |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 97629 |
| Policy instance | 1 |
| Insurance contract or identification number | 97629 | | Number of Individuals Covered | 66 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $13,431 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $223,421 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,431 | | Insurance broker organization code? | 3 | | Insurance broker name | ANDREINI & COMPANY |
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| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 663326 |
| Policy instance | 2 |
| Insurance contract or identification number | 663326 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $4,559 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $110,501 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,559 | | Insurance broker organization code? | 3 | | Insurance broker name | ANDREINI & COMPANY |
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