LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN
Plan identification number	501

LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare 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) Other welfare benefit cover

401k Sponsoring company profile

LOS ANGELES POLICE FEDERAL CREDIT UNION has sponsored the creation of one or more 401k plans.

Company Name:	LOS ANGELES POLICE FEDERAL CREDIT UNION
Employer identification number (EIN):	951683316
NAIC Classification:	522130
NAIC Description:	Credit Unions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01	JANET GASPARD	2021-07-12
501	2019-01-01
501	2018-03-01
501	2017-03-01
501	2016-03-01
501	2015-03-01
501	2014-03-01	NORMA FEDER-DONG
501	2013-03-01	NORMA FEDER-DONG
501	2012-03-01	NORMA FEDER-DONG
501	2011-03-01	NORMA FEDER-DONG
501	2010-03-01	NORMA FEDER-DONG
501	2009-03-01	NORMA FEDER-DONG
501	2008-03-01	NORMA FEDER-DONG

Plan Statistics for LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN

401k plan membership statisitcs for LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN

Measure	Date	Value
2022: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	147
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	154
Number of retired or separated participants receiving benefits	2022-01-01	1
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	155
2021: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	142
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	145
Number of retired or separated participants receiving benefits	2021-01-01	2
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	147
2020: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	144
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	142
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	142
Number of employers contributing to the scheme	2020-01-01	0
2019: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	150
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	141
Number of retired or separated participants receiving benefits	2019-01-01	3
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	144
2018: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-03-01	149
Total number of active participants reported on line 7a of the Form 5500	2018-03-01	147
Number of retired or separated participants receiving benefits	2018-03-01	3
Number of other retired or separated participants entitled to future benefits	2018-03-01	0
Total of all active and inactive participants	2018-03-01	150
2017: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-03-01	148
Total number of active participants reported on line 7a of the Form 5500	2017-03-01	146
Number of retired or separated participants receiving benefits	2017-03-01	3
Number of other retired or separated participants entitled to future benefits	2017-03-01	0
Total of all active and inactive participants	2017-03-01	149
2016: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-03-01	146
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	146
Number of retired or separated participants receiving benefits	2016-03-01	2
Number of other retired or separated participants entitled to future benefits	2016-03-01	0
Total of all active and inactive participants	2016-03-01	148
2015: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-03-01	152
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	145
Number of retired or separated participants receiving benefits	2015-03-01	0
Number of other retired or separated participants entitled to future benefits	2015-03-01	0
Total of all active and inactive participants	2015-03-01	145
2014: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-03-01	145
Total number of active participants reported on line 7a of the Form 5500	2014-03-01	151
Number of retired or separated participants receiving benefits	2014-03-01	3
Number of other retired or separated participants entitled to future benefits	2014-03-01	3
Total of all active and inactive participants	2014-03-01	157
2013: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-03-01	128
Total number of active participants reported on line 7a of the Form 5500	2013-03-01	144
Number of retired or separated participants receiving benefits	2013-03-01	0
Number of other retired or separated participants entitled to future benefits	2013-03-01	0
Total of all active and inactive participants	2013-03-01	144
2012: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-03-01	122
Total number of active participants reported on line 7a of the Form 5500	2012-03-01	128
Number of retired or separated participants receiving benefits	2012-03-01	0
Number of other retired or separated participants entitled to future benefits	2012-03-01	0
Total of all active and inactive participants	2012-03-01	128
2011: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-03-01	140
Total number of active participants reported on line 7a of the Form 5500	2011-03-01	135
Number of retired or separated participants receiving benefits	2011-03-01	1
Number of other retired or separated participants entitled to future benefits	2011-03-01	0
Total of all active and inactive participants	2011-03-01	136
2010: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-03-01	132
Total number of active participants reported on line 7a of the Form 5500	2010-03-01	142
Number of retired or separated participants receiving benefits	2010-03-01	5
Number of other retired or separated participants entitled to future benefits	2010-03-01	0
Total of all active and inactive participants	2010-03-01	147
2009: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-03-01	132
Total number of active participants reported on line 7a of the Form 5500	2009-03-01	130
Number of retired or separated participants receiving benefits	2009-03-01	2
Number of other retired or separated participants entitled to future benefits	2009-03-01	0
Total of all active and inactive participants	2009-03-01	132
2008: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2008 401k membership
Total participants, beginning-of-year	2008-03-01	125
Total number of active participants reported on line 7a of the Form 5500	2008-03-01	130
Number of retired or separated participants receiving benefits	2008-03-01	2
Number of other retired or separated participants entitled to future benefits	2008-03-01	0
Total of all active and inactive participants	2008-03-01	132

Form 5500 Responses for LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN

2022: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-03-01	Type of plan entity	Single employer plan
2018-03-01	Submission has been amended	No
2018-03-01	This submission is the final filing	No
2018-03-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2018-03-01	Plan is a collectively bargained plan	No
2018-03-01	Plan funding arrangement – Insurance	Yes
2018-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-03-01	Plan benefit arrangement – Insurance	Yes
2018-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-03-01	Type of plan entity	Single employer plan
2017-03-01	Submission has been amended	No
2017-03-01	This submission is the final filing	No
2017-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-03-01	Plan is a collectively bargained plan	No
2017-03-01	Plan funding arrangement – Insurance	Yes
2017-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-03-01	Plan benefit arrangement – Insurance	Yes
2017-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Submission has been amended	No
2016-03-01	This submission is the final filing	No
2016-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-03-01	Plan is a collectively bargained plan	No
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Submission has been amended	No
2015-03-01	This submission is the final filing	No
2015-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-03-01	Plan is a collectively bargained plan	No
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-03-01	Type of plan entity	Single employer plan
2014-03-01	Submission has been amended	No
2014-03-01	This submission is the final filing	No
2014-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-03-01	Plan is a collectively bargained plan	No
2014-03-01	Plan funding arrangement – Insurance	Yes
2014-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-03-01	Plan benefit arrangement – Insurance	Yes
2014-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	Submission has been amended	No
2013-03-01	This submission is the final filing	No
2013-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-03-01	Plan is a collectively bargained plan	No
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	Submission has been amended	No
2012-03-01	This submission is the final filing	No
2012-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-03-01	Plan is a collectively bargained plan	No
2012-03-01	Plan funding arrangement – Insurance	Yes
2012-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes
2012-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-03-01	Type of plan entity	Single employer plan
2011-03-01	Submission has been amended	No
2011-03-01	This submission is the final filing	No
2011-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-03-01	Plan is a collectively bargained plan	No
2011-03-01	Plan funding arrangement – Insurance	Yes
2011-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-03-01	Plan benefit arrangement – Insurance	Yes
2011-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-03-01	Type of plan entity	Single employer plan
2010-03-01	Submission has been amended	No
2010-03-01	This submission is the final filing	No
2010-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-03-01	Plan is a collectively bargained plan	No
2010-03-01	Plan funding arrangement – Insurance	Yes
2010-03-01	Plan benefit arrangement – Insurance	Yes
2009: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-03-01	Type of plan entity	Single employer plan
2009-03-01	Submission has been amended	No
2009-03-01	This submission is the final filing	No
2009-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-03-01	Plan is a collectively bargained plan	No
2009-03-01	Plan funding arrangement – Insurance	Yes
2009-03-01	Plan benefit arrangement – Insurance	Yes
2008: LOS ANGELES POLICE FEDERAL CREDIT UNION HEALTH AND WELFARE PLAN 2008 form 5500 responses
2008-03-01	Type of plan entity	Single employer plan
2008-03-01	Submission has been amended	No
2008-03-01	This submission is the final filing	No
2008-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-03-01	Plan is a collectively bargained plan	No
2008-03-01	Plan funding arrangement – Insurance	Yes
2008-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	555497
Policy instance	2
Insurance contract or identification number 555497 Number of Individuals Covered 146 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $12,521 Total amount of fees paid to insurance company USD $1,090 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit 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 $125,207 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,654 Amount paid for insurance broker fees 1090 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number	480216
Policy instance	1
Insurance contract or identification number 480216 Number of Individuals Covered 16 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $496 Total amount of fees paid to insurance company USD $3 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,693 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $487 Insurance broker organization code? 3 Amount paid for insurance broker fees 3 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG 0AZMF
Policy instance	3
Insurance contract or identification number GUG 0AZMF Number of Individuals Covered 153 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,615 Total amount of fees paid to insurance company USD $859 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit 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 $10,766 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $503 Amount paid for insurance broker fees 859 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226760
Policy instance	4
Insurance contract or identification number 226760 Number of Individuals Covered 188 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $50,001 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $894,981 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $31,222 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AZMF
Policy instance	5
Insurance contract or identification number GVTL0AZMF Number of Individuals Covered 87 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $5,567 Total amount of fees paid to insurance company USD $2,632 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $37,112 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,873 Amount paid for insurance broker fees 2632 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AZMF
Policy instance	6
Insurance contract or identification number GLUG0AZMF Number of Individuals Covered 153 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $6,101 Total amount of fees paid to insurance company USD $3,247 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $40,675 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,901 Amount paid for insurance broker fees 3247 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	S1819/N4967
Policy instance	7
Insurance contract or identification number S1819/N4967 Number of Individuals Covered 42 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $54,760 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $914,711 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $36,963 Insurance broker organization code? 3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number	480217
Policy instance	11
Insurance contract or identification number 480217 Number of Individuals Covered 30 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,512 Total amount of fees paid to insurance company USD $333 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CRITICAL ILLNESS 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 $10,075 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,076 Amount paid for insurance broker fees 333 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AZMF
Policy instance	10
Insurance contract or identification number GLTD0AZMF Number of Individuals Covered 153 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $3,779 Total amount of fees paid to insurance company USD $2,013 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $25,197 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,183 Amount paid for insurance broker fees 2013 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	10056331001
Policy instance	9
Insurance contract or identification number 10056331001 Number of Individuals Covered 290 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $2,114 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 $19,643 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,322 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	0000532894
Policy instance	8
Insurance contract or identification number 0000532894 Number of Individuals Covered 2 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $50 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided INDIVIDUAL DISABILITY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,184 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $50 Insurance broker organization code? 3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number	480218
Policy instance	12
Insurance contract or identification number 480218 Number of Individuals Covered 11 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $467 Total amount of fees paid to insurance company USD $7 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided HOSPITAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,113 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $445 Insurance broker organization code? 3 Amount paid for insurance broker fees 7 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG 0AZMF
Policy instance	5
Insurance contract or identification number GUG 0AZMF Number of Individuals Covered 147 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,482 Total amount of fees paid to insurance company USD $739 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit 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 $9,882 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,098 Amount paid for insurance broker fees 554 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226760
Policy instance	1
Insurance contract or identification number 226760 Number of Individuals Covered 193 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $40,666 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $773,972 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $40,666 Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	9038036
Policy instance	2
Insurance contract or identification number 9038036 Number of Individuals Covered 8 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $83 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENT AND CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,201 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $83 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0335380
Policy instance	3
Insurance contract or identification number R0335380 Number of Individuals Covered 16 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $279 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENT, CRITICAL ILLNESS AND HOSPITAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,257 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $279 Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	555497
Policy instance	4
Insurance contract or identification number 555497 Number of Individuals Covered 142 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $10,354 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit 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 $103,542 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,354 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AZMF
Policy instance	6
Insurance contract or identification number GLUG0AZMF Number of Individuals Covered 147 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $5,603 Total amount of fees paid to insurance company USD $2,793 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $37,355 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,151 Amount paid for insurance broker fees 2095 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	S1819/N4967
Policy instance	7
Insurance contract or identification number S1819/N4967 Number of Individuals Covered 41 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $47,641 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $801,786 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $47,641 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	10056331001
Policy instance	8
Insurance contract or identification number 10056331001 Number of Individuals Covered 274 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $2,012 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 $18,625 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,012 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AZMF
Policy instance	9
Insurance contract or identification number GVTL0AZMF Number of Individuals Covered 70 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $4,501 Total amount of fees paid to insurance company USD $2,264 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $30,002 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,339 Amount paid for insurance broker fees 1698 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AZMF
Policy instance	10
Insurance contract or identification number GLTD0AZMF Number of Individuals Covered 147 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $3,475 Total amount of fees paid to insurance company USD $1,713 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $23,164 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,572 Amount paid for insurance broker fees 1285 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	10056331001
Policy instance	1
Insurance contract or identification number 10056331001 Number of Individuals Covered 261 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $2,440 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,297 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,816 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0335380
Policy instance	2
Insurance contract or identification number R0335380 Number of Individuals Covered 16 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,182 Total amount of fees paid to insurance company USD $24 Other welfare benefits provided ACCIDENT, CRITICAL ILLNESS, HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $4,504 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,179 Amount paid for insurance broker fees 24 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	555497
Policy instance	3
Insurance contract or identification number 555497 Number of Individuals Covered 136 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $9,962 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $99,620 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,962 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	9038036
Policy instance	4
Insurance contract or identification number 9038036 Number of Individuals Covered 8 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $83 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENT, CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $2,201 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $83 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	N4967A/S1819A
Policy instance	5
Insurance contract or identification number N4967A/S1819A Number of Individuals Covered 38 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $43,893 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $733,329 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $43,893 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	226760
Policy instance	6
Insurance contract or identification number 226760 Number of Individuals Covered 180 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $43,576 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $924,208 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $43,576 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AZMF
Policy instance	7
Insurance contract or identification number GLUG0AZMF Number of Individuals Covered 142 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $14,078 Total amount of fees paid to insurance company USD $6,159 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 Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $93,851 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,078 Amount paid for insurance broker fees 4264 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	10056331001
Policy instance	1
Insurance contract or identification number 10056331001 Number of Individuals Covered 250 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $632 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,377 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $632 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0335380
Policy instance	2
Insurance contract or identification number R0335380 Number of Individuals Covered 14 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $30 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY ACCIDENT, CRITICAL ILLNESS, VOLUNTARY HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $4,035 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AZMF
Policy instance	3
Insurance contract or identification number GVTL0AZMF Number of Individuals Covered 64 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $4,358 Total amount of fees paid to insurance company USD $1,258 Life Insurance Welfare Benefit Yes Other welfare benefits provided VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $29,056 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,358 Amount paid for insurance broker fees 1258 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00555497
Policy instance	4
Insurance contract or identification number 00555497 Number of Individuals Covered 136 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $11,268 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $104,818 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,482 Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0009038036
Policy instance	5
Insurance contract or identification number 0009038036 Number of Individuals Covered 11 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $102 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENT, CRITICAL ILLESS Welfare Benefit Premiums Paid to Carrier USD $2,708 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $102 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG 0AZMF
Policy instance	8
Insurance contract or identification number GUG 0AZMF Number of Individuals Covered 141 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,388 Total amount of fees paid to insurance company USD $320 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $9,254 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,388 Amount paid for insurance broker fees 320 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AZMF
Policy instance	6
Insurance contract or identification number GLTD0AZMF Number of Individuals Covered 141 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $3,220 Total amount of fees paid to insurance company USD $743 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $21,467 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,220 Amount paid for insurance broker fees 743 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	N4967A/S1819A
Policy instance	9
Insurance contract or identification number N4967A/S1819A Number of Individuals Covered 43 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $50,852 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $868,830 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $50,852 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226760
Policy instance	10
Insurance contract or identification number 226760 Number of Individuals Covered 167 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $34,531 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $722,953 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,531 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AZMF
Policy instance	11
Insurance contract or identification number GLUG0AZMF Number of Individuals Covered 141 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $5,247 Total amount of fees paid to insurance company USD $610 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $34,982 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,247 Amount paid for insurance broker fees 610 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	629003 0150
Policy instance	9
Insurance contract or identification number 629003 0150 Number of Individuals Covered 2 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $101 Total amount of fees paid to insurance company USD $8 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $952 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $101 Amount paid for insurance broker fees 8 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	N4967A/S1819A
Policy instance	10
Insurance contract or identification number N4967A/S1819A Number of Individuals Covered 54 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $47,659 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $819,338 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $47,659 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226760
Policy instance	11
Insurance contract or identification number 226760 Number of Individuals Covered 158 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $34,373 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $792,918 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,373 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AZMF
Policy instance	12
Insurance contract or identification number GLUG0AZMF Number of Individuals Covered 147 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $2,184 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $14,563 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,184 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG 0AZMF
Policy instance	8
Insurance contract or identification number GUG 0AZMF Number of Individuals Covered 147 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $1,149 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,658 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,149 Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	629003 0001
Policy instance	7
Insurance contract or identification number 629003 0001 Number of Individuals Covered 50 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $5,561 Total amount of fees paid to insurance company USD $417 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $49,930 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,561 Amount paid for insurance broker fees 417 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	10056331001
Policy instance	1
Insurance contract or identification number 10056331001 Number of Individuals Covered 280 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $1,617 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $16,154 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,617 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	629003
Policy instance	2
Insurance contract or identification number 629003 Number of Individuals Covered 147 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $2,108 Total amount of fees paid to insurance company USD $178 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $23,692 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,108 Amount paid for insurance broker fees 178 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AZMF
Policy instance	3
Insurance contract or identification number GVTL0AZMF Number of Individuals Covered 71 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $4,500 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $29,998 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,500 Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	629003 0100
Policy instance	4
Insurance contract or identification number 629003 0100 Number of Individuals Covered 89 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $1,817 Total amount of fees paid to insurance company USD $136 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $16,510 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,817 Amount paid for insurance broker fees 136 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AZMF
Policy instance	5
Insurance contract or identification number GLTD0AZMF Number of Individuals Covered 147 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $2,663 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $17,753 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,663 Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	629003 0701
Policy instance	6
Insurance contract or identification number 629003 0701 Number of Individuals Covered 1 Insurance policy start date 2018-03-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $150 Total amount of fees paid to insurance company USD $11 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,359 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $150 Amount paid for insurance broker fees 11 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	10056331001
Policy instance	1
Insurance contract or identification number 10056331001 Number of Individuals Covered 279 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $2,080 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $20,865 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,080 Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	629003
Policy instance	2
Insurance contract or identification number 629003 Number of Individuals Covered 144 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $2,595 Total amount of fees paid to insurance company USD $277 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $29,937 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,595 Amount paid for insurance broker fees 277 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AZMF
Policy instance	3
Insurance contract or identification number GVTL0AZMF Number of Individuals Covered 74 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $5,374 Total amount of fees paid to insurance company USD $1,112 Life Insurance Welfare Benefit Yes Other welfare benefits provided VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $35,828 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,374 Amount paid for insurance broker fees 1112 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AZMF
Policy instance	4
Insurance contract or identification number GLTD0AZMF Number of Individuals Covered 146 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $3,124 Total amount of fees paid to insurance company USD $565 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $20,826 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,124 Amount paid for insurance broker fees 565 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG 0AZMF
Policy instance	6
Insurance contract or identification number GUG 0AZMF Number of Individuals Covered 146 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $1,356 Total amount of fees paid to insurance company USD $245 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $9,041 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,356 Amount paid for insurance broker fees 245 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES INC.
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	629003
Policy instance	5
Insurance contract or identification number 629003 Number of Individuals Covered 136 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $9,384 Total amount of fees paid to insurance company USD $776 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $96,180 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,384 Amount paid for insurance broker fees 776 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES INC.
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	N4967A/S1819A
Policy instance	7
Insurance contract or identification number N4967A/S1819A Number of Individuals Covered 58 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $49,350 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $842,678 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $49,350 Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226760
Policy instance	8
Insurance contract or identification number 226760 Number of Individuals Covered 152 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $35,643 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $750,408 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35,643 Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AZMF
Policy instance	9
Insurance contract or identification number GLUG0AZMF Number of Individuals Covered 146 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $2,603 Total amount of fees paid to insurance company USD $465 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $17,355 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,603 Amount paid for insurance broker fees 465 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226760
Policy instance	3
Insurance contract or identification number 226760 Number of Individuals Covered 135 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $29,431 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $617,332 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,821 Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	N4967A
Policy instance	2
Insurance contract or identification number N4967A Number of Individuals Covered 142 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $56,708 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $899,425 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $52,016 Insurance broker organization code? 3 Insurance broker name MANIACI INSURANCE SERVICES, INC.
AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )
Policy contract number	C5433B
Policy instance	1
Insurance contract or identification number C5433B Number of Individuals Covered 145 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $12,142 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $60,712 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,142 Insurance broker organization code? 3 Insurance broker name BICHLMEIER INSURANCE SERVICES
AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )
Policy contract number	C1773N
Policy instance	4
Insurance contract or identification number C1773N Number of Individuals Covered 73 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $6,137 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $30,683 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,137 Insurance broker organization code? 3 Insurance broker name BICHLMEIER INSURANCE SERVICES
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	144584
Policy instance	3
Insurance contract or identification number 144584 Number of Individuals Covered 18 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $2,976 Total amount of fees paid to insurance company USD $88 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $27,748 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,788 Insurance broker organization code? 3 Amount paid for insurance broker fees 88 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker name NFP INSURANCE SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226760
Policy instance	1
Insurance contract or identification number 226760 Number of Individuals Covered 133 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $28,301 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 $547,898 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,301 Insurance broker organization code? 3 Insurance broker name BICHLMEIER INSURANCE SERVICES, INC.
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	N4967A/S1819A
Policy instance	2
Insurance contract or identification number N4967A/S1819A Number of Individuals Covered 107 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $44,156 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 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 $791,761 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $44,156 Insurance broker organization code? 3 Insurance broker name BICHLMEIER INSURANCE SERVICES, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	931510/532894
Policy instance	4
Insurance contract or identification number 931510/532894 Number of Individuals Covered 151 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $12,144 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 Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $90,323 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,637 Insurance broker organization code? 3 Insurance broker name FMS INSURANCE SERVICES, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	931510/532894
Policy instance	4
Insurance contract or identification number 931510/532894 Number of Individuals Covered 148 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $6,142 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 Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $66,636 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,582 Insurance broker organization code? 3 Insurance broker name FMS INSURANCE SERVICES, INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	144584
Policy instance	3
Insurance contract or identification number 144584 Number of Individuals Covered 18 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $3,161 Total amount of fees paid to insurance company USD $105 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $26,956 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,964 Insurance broker organization code? 3 Amount paid for insurance broker fees 105 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker name FMS INSURANCE SERVICES, INC.
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	Z4012A/Z3952A
Policy instance	2
Insurance contract or identification number Z4012A/Z3952A Number of Individuals Covered 136 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $39,369 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 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 $760,686 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39,369 Insurance broker organization code? 3 Insurance broker name BICHLMEIER INSURANCE SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226760
Policy instance	1
Insurance contract or identification number 226760 Number of Individuals Covered 121 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $23,584 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 $537,926 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,584 Insurance broker organization code? 3 Insurance broker name BICHLMEIER INSURANCE SERVICES, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	931510/532894
Policy instance	4
Insurance contract or identification number 931510/532894 Number of Individuals Covered 134 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $6,929 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 Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $70,479 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,263 Insurance broker organization code? 3 Insurance broker name FMS INSURANCE SERVICES, INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	144584
Policy instance	3
Insurance contract or identification number 144584 Number of Individuals Covered 20 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $3,035 Total amount of fees paid to insurance company USD $119 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $23,821 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,674 Insurance broker organization code? 3 Amount paid for insurance broker fees 119 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker name NFP INSURANCE SERVICES, INC.
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	Z4012A/Z3952A
Policy instance	2
Insurance contract or identification number Z4012A/Z3952A Number of Individuals Covered 126 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $36,269 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 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 $649,497 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $36,269 Insurance broker organization code? 3 Insurance broker name BICHLMEIER INSURANCE SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226760
Policy instance	1
Insurance contract or identification number 226760 Number of Individuals Covered 106 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $21,953 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 $460,249 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,903 Insurance broker organization code? 3 Insurance broker name PACIFIC INSURANCE MANAGEMENT CORP.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	931510
Policy instance	6
Insurance contract or identification number 931510 Number of Individuals Covered 134 Insurance policy start date 2011-03-01 Insurance policy end date 2012-02-29 Total amount of commissions paid to insurance broker USD $6,812 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 Yes Long Term Disability Insurance Welfare Benefit Yes 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 $51,156 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	532894
Policy instance	5
Insurance contract or identification number 532894 Number of Individuals Covered 12 Insurance policy start date 2011-03-01 Insurance policy end date 2012-02-29 Total amount of commissions paid to insurance broker USD $890 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,067 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	144584
Policy instance	4
Insurance contract or identification number 144584 Number of Individuals Covered 21 Insurance policy start date 2011-03-01 Insurance policy end date 2012-02-29 Total amount of commissions paid to insurance broker USD $4,835 Total amount of fees paid to insurance company USD $255 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $25,172 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	865031G
Policy instance	3
Insurance contract or identification number 865031G Number of Individuals Covered 128 Insurance policy start date 2011-03-01 Insurance policy end date 2012-02-29 Total amount of commissions paid to insurance broker USD $482 Total amount of fees paid to insurance company USD $361 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 Yes Long Term Disability Insurance Welfare Benefit Yes 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 $7,224 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 number	Z3952A
Policy instance	2
Insurance contract or identification number Z3952A Number of Individuals Covered 127 Insurance policy start date 2011-03-01 Insurance policy end date 2012-02-29 Total amount of commissions paid to insurance broker USD $38,097 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 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 $682,907 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	226760
Policy instance	1
Insurance contract or identification number 226760 Number of Individuals Covered 102 Insurance policy start date 2011-03-01 Insurance policy end date 2012-02-29 Total amount of commissions paid to insurance broker USD $20,924 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 $401,436 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN SPECIALTY HEALTH PLANS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	14191
Policy instance	4
Insurance contract or identification number 14191 Number of Individuals Covered 129 Insurance policy start date 2010-03-01 Insurance policy end date 2011-02-28 Total amount of commissions paid to insurance broker USD $970 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CHIROPRACTIC/ACUPUNCTURE 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 $11,981 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $970 Insurance broker organization code? 3 Insurance broker name BICHLMEIER INSURANCE SERVICES, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	865031G
Policy instance	3
Insurance contract or identification number 865031G Number of Individuals Covered 142 Insurance policy start date 2010-03-01 Insurance policy end date 2011-02-28 Total amount of commissions paid to insurance broker USD $13,228 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 Yes Long Term Disability Insurance Welfare Benefit Yes 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 $92,857 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,289 Insurance broker organization code? 3 Insurance broker name CENTERSTONE INSURANCE AND FINANCIAL
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	76264A/C
Policy instance	2
Insurance contract or identification number 76264A/C Number of Individuals Covered 133 Insurance policy start date 2010-03-01 Insurance policy end date 2011-02-28 Total amount of commissions paid to insurance broker USD $32,452 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 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 $586,588 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32,452 Insurance broker organization code? 3 Insurance broker name BICHLMEIER INSURANCE SERVICES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	226760
Policy instance	1
Insurance contract or identification number 226760 Number of Individuals Covered 105 Insurance policy start date 2010-03-01 Insurance policy end date 2011-02-28 Total amount of commissions paid to insurance broker USD $16,528 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 $360,501 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,528 Insurance broker organization code? 3 Insurance broker name BICHLMEIER INSURANCE SERVICES, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	532894
Policy instance	6
Insurance contract or identification number 532894 Number of Individuals Covered 12 Insurance policy start date 2010-03-01 Insurance policy end date 2011-02-28 Total amount of commissions paid to insurance broker USD $1,237 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,722 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,190 Insurance broker organization code? 3 Insurance broker name FMS INSURANCE SERVICES, INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	144584
Policy instance	5
Insurance contract or identification number 144584 Number of Individuals Covered 21 Insurance policy start date 2010-03-01 Insurance policy end date 2011-02-28 Total amount of commissions paid to insurance broker USD $5,696 Total amount of fees paid to insurance company USD $1,027 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $16,212 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,974 Amount paid for insurance broker fees 503 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name NFP INSURANCE SERVICES, INC.

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• LOS ANGELES INSTITUTE FOR OPHTHALMIC SURGERY PROFIT SHARING PLAN [EIN = 953519316]
• LOS ANGELES CENTERS FOR ALCOHOL AND DRUG ABUSE 403(B) PLAN [EIN = 237110152]
• LOS ANGELES LIGHTING MFG. CO. INC. 401(K) PLAN [EIN = 954180394]
• LOS ANGELES AIR BALANCE CO INC 401 K PROFIT SHARING PLAN TRUST [EIN = 954325564]
• LOS ANGELES CHAPTER, NATIONAL TOOLING AND MACHIN 401-K PLAN [EIN = 952540850]
• LOS ANGELES CONSERVANCY 401(K) PLAN [EIN = 953273046]
• LOS ANGELES BUNKER SERVICES, INC. RETIREMENT PLAN [EIN = 330495273]
• LOS ANGELES ARBORETUM FOUNDATION 401K PLAN [EIN = 951582650]
• LOS ANGELES HOSPICE, INC. 401K PROFIT SHARING PLAN [EIN = 954889905]
• LOS ANGELES SPORTING CLUB INC. 401K PLAN [EIN = 953908555]
• LOS ANGELES AND ORANGE COUNTY ADJUSTMENT BUREAU PROFIT SHARING PLAN [EIN = 952794950]
• LOS ANGELES GALVANIZING COMPANY 401K PROFIT SHARING PLAN [EIN = 950949310]
• LOS ANGELES BY-PRODUCTS, CO. 401(K) PROFIT SHARING PLAN [EIN = 950947700]
• LOS ANGELES IMMIGRATION ATTORNEY, INC. CASH BALANCE PENSION PLAN [EIN = 463105778]
• LOS ANGELES HEMATOLOGY/OMG 401K [EIN = 954332724]
• LOS ANGELES RADIOLOGY MEDICAL ASSOCIATES, INC. DEFINED BENEFIT PENSION PLAN [EIN = 300385680]
• LOS ANGELES VASCULAR SERVICE INC. RETIREMENT PLAN [EIN = 453452847]
• LOS ANGELES EAR, NOSE & THROAT ASSOCIATES 401(K) PROFIT SHARING PLAN [EIN = 954403038]
• LOS ANGELES MARITIME INSTITUTE 401K PROFIT SHARING PLAN & TRUST [EIN = 330515416]
• LOS ANGELES BOYS & GIRLS CLUB PENSION PLAN [EIN = 237304197]
• LOS ANGELES CARDIOVASCULAR AND 401 K PROFIT SHARING PLAN TRUST [EIN = 262781960]
• LOS ANGELES HOME HEALTH CARE INC 401K PLAN [EIN = 954861160]
• LOS ANGELES CHARTER SCHOOL ORG 401 K PROFIT SHARING PLAN TRUST [EIN = 900982719]
• LOS ANGELES SPEECH & LANGUAGE THERAPY CENTER, INC. 401(K) PROFIT SHARING PLAN [EIN = 954559127]
• LOS ANGELES BY-PRODUCTS CO. DEFINED BENEFIT PENSION PLAN [EIN = 950947700]
• LOS ANGELES COMMUNITIES ADVOCATING FOR UNITY, SOCIAL JUSTICE AND ACTION, INC. 401(K) PROFIT SHARING PLAN & TRUST [EIN = 320150097]
• LOS ANGELES OPHTHALMOLOGY MEDICAL GROUP, INC. DEFINED BENEFIT PENSION PLAN [EIN = 371467502]
• LOS ANGELES FINE ART GALLERY DDC PLAN [EIN = 954298413]
• LOS ANGELES IMMIGRATION ATTORNEY, INC. 401(K) PROFIT SHARING PLAN [EIN = 463105778]
• LOS ANGELES SILK SCREEN CO INC 401 K PROFIT SHARING PLAN TRUST [EIN = 953172027]
• LOS ANGELES CENTER FOR LAW AND JUSTICE 403(B) PLAN [EIN = 952690540]
• LOS ANGELES NATIONAL BANK 401(K) PLAN [EIN = 952805541]
• LOS ANGELES REAL ESTATE MANAGEMENT, INC. CASH BALANCE PLAN [EIN = 954370289]
• LOS ANGELES SPORTS COUNCIL DEFINED BENEFIT PENSION PLAN [EIN = 954201530]
• LOS ANGELES SPORTS COUNCIL 401(K) PLAN [EIN = 954201530]
• LOS ANGELES CARDIOVASCULAR CONSULTANTS MEDICAL GROUP, INC. DEFINED BENEFIT PENSION PLAN [EIN = 953409915]
• LOS ANGELES PM & R MEDICAL GROUP, INC. PROFIT SHARING PLAN [EIN = 205021948]
• LOS ANGELES CABLE TELEVISION A 401 K PROFIT SHARING PLAN TRUST [EIN = 954521370]
• LOS ANGELES VISION CENTER INC. RETIREMENT TRUST [EIN = 202218848]
• LOS ANGELES CHAMBER ORCHESTRA SOCIETY INC 401(K) PLAN [EIN = 237010825]
• LOS ANGELES YOUTH NETWORK 403(B) PLAN [EIN = 953953979]
• LOS ANGELES LOMOD CORPORATION 401(K) PLAN [EIN = 953033333]
• LOS ANGELES HOSPICE, INC. DEFINED BENEFIT PENSION PLAN [EIN = 954889905]
• LOS ANGELES FIREMEN'S RELIEF ASSOCIATION 401(K) PLAN [EIN = 951647833]
• LOS ANGELES OPHTHALMOLOGY MEDICAL GROUP, INC. 401(K) PROFIT SHARING PLAN [EIN = 371467502]
• LOS ANGELES FINE ART GALLERY DEFINED BENEFIT PENSION PLAN [EIN = 954298413]
• LOS ANGELES AIR CONDITIONING, INC. 401(K) PROFIT SHARING PLAN [EIN = 952214658]
• LOS ANGELES PERINATAL ASSOCIATES, AMC PROFIT SHARING PLAN AND TRUST [EIN = 452161988]
• LOS ANGELES POLICE RELIEF ASSOCIATION, INC. 401(K) RETIREMENT SERVICES PLAN [EIN = 951660854]
• LOS ANGELES METAL REFINISHING 401 K PROFIT SHARING PLAN TRUST [EIN = 953911785]
• LOS ANGELES MISSION, INC. RETIREMENT PLAN [EIN = 953134049]
• LOS ANGELES PLUMBING & BACKFLOW TESTING, INC 401K PLAN [EIN = 954706054]
• LOS ANGELES BUSINESS FORMS, INC. 401(K) SAVINGS PLAN [EIN = 954101216]
• LOS ANGELES REGIONAL FOOD BANK - FLEXIBLE BENEFITS PLAN [EIN = 953135649]
• LOS ANGELES POLICE RETIREMENT BENEFIT & INSURANCE ASSOCIATION INC [EIN = 956048123]
• LOS ANGELES HOTEL-RESTAURANT EMPLOYER-UNION WELFARE FUND RETIREMENT PLAN [EIN = 951776480]
• LOS ANGELES POLICE PROTECTIVE LEAGUE LEGAL DEFENSE PLAN [EIN = 950949173]
• LOS ANGELES URBAN LEAGUE WELFARE BENEFITS PLAN [EIN = 951691288]
• LOS ANGELES CONSERVATION CORPS 401(K) RETIREMENT PLAN [EIN = 954002138]
• LOS ANGELES COUNTY FAIR ASSOCIATION WELFARE BENEFIT PLAN [EIN = 951660585]
• LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN [EIN = 951690974]
• LOS ANGELES PHILHARMONIC ASSOC AND MUSICIAN UNION, LOCAL 47, AMERICAN FEDERATION OF MUSICIANS PENSION TRUST [EIN = 951696734]
• LOS ANGELES BIOMEDICAL RESEARCH INSTITUTE AT HARBOR-UCLA MEDICAL [EIN = 952138184]
• LOS ANGELES MACHINIST BENEFIT TRUST [EIN = 952755074]
• LOS ANGELES CAPITAL MASTER COLLECTIVE INVESTMENT TRUST [EIN = 463245950]
• LOS ANGELES COLLECTIVE LLC 401(K) PLAN [EIN = 263747934]
• LOS ANGELES FAMILY SCHOOL 403(B) PLAN [EIN = 952825348]
• LOS ANGELES UNIVERSAL PRESCHOOL WELFARE BENEFITS PLAN [EIN = 223902958]
• LOS ANGELES CHRISTIAN HEALTH CENTERS WELFARE BENEFITS PLAN [EIN = 954315734]
• LOS ANGELES JEWISH HOME FOR THE AGING EMPLOYEE BENEFIT PLAN [EIN = 953510024]
• LOS ANGELES AIR BALANCE CO INC 401K PROFIT SHARING PLAN & TRUST [EIN = 954325565]
• LOS ANGELES ORT TECHNICAL INSTITUTE 401(K) PROFIT SHARING PLAN & TRUST [EIN = 133281910]
• LOS ANGELES ALLIANCE FOR A NEW ECONOMY - FLEXIBLE BENEFITS PLAN [EIN = 954459427]
• LOS ANGELES TEAM MENTORING 401(K) PLAN [EIN = 954443617]
• LOS ANGELES LIGHTING MANUFACTU 401 K PROFIT SHARING PLAN TRUST [EIN = 954180394]
• LOS ANGELES HOUSE OF RUTH 401(K) PLAN [EIN = 953411454]
• LOS ANGELES PROFESSIONAL PRACTICE MANAGEMENT ASSOCIATES, INC. PROFIT SHARING PLAN [EIN = 330869380]
• LOS ANGELES LDC, INC EMPLOYEE SAVINGS FUND [EIN = 953532380]
• LOS ANGELES HARLEY DAVIDSON INCORPORATED RETIREMENT PLAN [EIN = 954120567]
• LOS ANGELES ART GLASS CORP. EMPLOYEE STOCK OWNERSHIP PLAN [EIN = 950947210]
• LOS ANGELES COUNTY MEDICAL ASSOCIATION EMPLOYEES SAVING TRUST [EIN = 950948250]
• LOS ANGELES TIMES COMMUNICATIONS LLC AND PARTICIPATING EMPLOYERS EMPLOYEE INVOLUNTARY SEPARATION PLAN FALL 2008 [EIN = 364371324]
• LOS ANGELES FREIGHTLINER, INC. HEALTH & WELFARE PLAN [EIN = 953118704]
• LOS ANGELES REPRODUCTIVE CENTE 401 K PROFIT SHARING PLAN TRUST [EIN = 812473801]
• LOS ANGELES KO BOXING CLUB AND TRAINING STUDIO, LLC 401(K) PROFIT SHARING PLAN [EIN = 471749200]
• LOS ANGELES PUMPING CO., LLC 401(K) PLAN [EIN = 510594976]
• LOS ANGELES SHERIFF'S PROFESSIONAL ASSOCIATION 401K PL [EIN = 954745150]
• LOS ANGELES PROFESSIONAL PRACTICE MANAGEMENT ASSOCIATES, LLC 401(K) PROFIT SHARING PLAN [EIN = 330869380]
• LOS ANGELES CONSTRUCTION & DEV 401(K) PROFIT SHARING PLAN & TRUST [EIN = 814826280]
• LOS ANGELES IVF LABORATORY LLC 401(K) PROFIT SHARING PLAN & TRUST [EIN = 823186234]
• LOS ANGELES INTEGRATIVE GASTROENTEROLOGY & NUTRITION, INC. RETIREMENT PLAN [EIN = 900451066]
• LOS ANGELES INTEGRATIVE GASTROENTEROLOGY & NUTRITION, INC. PROFIT SHARING PLAN [EIN = 900451066]
• LOS ANGELES SHERIFF'S PROFESSIONAL ASSOCIATION BENEFIT PLAN [EIN = 842904861]
• LOS ANGELES MOTOR CARS WELFARE BENEFIT PLAN [EIN = 831098410]
• LOS ANGELES COLLEGE OF MUSIC 401(K) PLAN [EIN = 954561188]
• LOS ANGELES CDJR 401(K) RETIREMENT PLAN [EIN = 831098410]
• LOS ANGELES PROFESSIONAL PRACTICE MANAGEMENT ASSOCIATES, LLC DEFINED BENEFIT PENSION PLAN [EIN = 330869380]
• LOS ANGELES SALAD INTERNATIONAL, LLC 401(K) PROFIT SHARING PLAN [EIN = 010841496]
• LOS ANGELES WATERKEEPER RETIREMENT PLAN [EIN = 954444787]
• LOS ANGELES POLICE PROTECTIVE LEAGUE LEGAL DEFENSE PLAN TRUST [EIN = 856190848]
• LOS ANGELES COUNTY MEDICAL ASSOCIATION EMPLOYEES RETIREMENT SAVINGS PLAN [EIN = 950948250]
• LOS ANGELES CHAPTER OF THE NAT 401(K) PROFIT SHARING PLAN & TRUST [EIN = 952540850]
• LOS ANGELES ELECTRIC CO. 401(K) PROFIT SHARING PLAN [EIN = 952240458]
• LOS ANGELES MOTOR CARS, INC. [EIN = 831098410]
• LOS ANGELES PROPERTY MANAGEMENT GROUP 401(K) PLAN [EIN = 954133628]
• LOS ANGELES 10TH DISTRICT PTSA 401(K) PLAN [EIN = 951782319]
• LOS ANGELES MACHINERY MOVING INC 401(K) P/S PLAN [EIN = 954566038]
• LOS ANGELES NEUROSCIENCES, INC. 401(K) PROFIT SHARING PLAN [EIN = 824791007]
• LOS ANGELES COUNTY BICYCLING COALITION 401(K) PLAN [EIN = 954845170]
• LOS ANGELES DISTRIBUTING 401(K) PLAN [EIN = 800784076]
• LOS ANGELES VASCULAR SERVICES INC. PROFIT SHARING PLAN & TRUST [EIN = 453452847]
• LOS ANGELES VASCULAR SERVICES INC. CASH BALANCE PENSION PLAN & TRUST [EIN = 453452847]
• LOS ANGELES CARDIOLOGY ASSOCIATES 401(K) PLAN [EIN = 364975119]
• LOS ANGELES AIR CONDITIONING, INC. 401(K) PROFIT SHARING PLAN [EIN = 952214658]
• LOS ANGELES JEWISH HOME FOR THE AGING STD PLAN [EIN = 953510024]
• LOS ANGELES APPAREL 401(K) PLAN [EIN = 813121592]
• LOS ANGELES HOUSING COMPLIANCE 401(K) PLAN [EIN = 843691187]
• LOS ANGELES PERFORMANCE PRACTICE 401(K) PLAN [EIN = 812571475]
• LOS ANGELES WATCHWORKS 401(K) PLAN [EIN = 812655222]
• LOS ANGELES COUNTY USC MEDICAL CENTER AUXILIARY 401K [EIN = 237036745]
• LOS ANGELES INNOCENCE PROJECT INC 401K PLAN [EIN = 920321417]
• LOS ANGELES FLOWER DISTRICT 401(K) PLAN [EIN = 954725965]
• LOS ANGELES ORGANIZING COMMITTEE FOR OLYMPIC & PARALYMPIC GAMES HEALTH AND WELFARE PLANS [EIN = 472018941]
• LOS ANGELES APPAREL [EIN = 813121592]
• LOS ANGELES COUNTY CHICANO EMPLOYEES ASSOCIATION 401(K) PLAN [EIN = 952883629]
• LOS ANGELES ENDOSCOPE CENTER LLC 401(K) PLAN [EIN = 811925737]
• LOS ANGELES INSTITUTE OF FOOT AND ANKLE 401K PLAN [EIN = 331091278]
• LOS ANGELES FAMILY MEDICAL SERVICES 401K [EIN = 271999505]
• LOS ANGELES PARKS FOUNDATION [EIN = 262358338]
• LOS ANGELES LIGHTING [EIN = 200425706]
• LOS ANGELES SENTINEL INC [EIN = 952673465]
• LOS ANGELES WORLDCPS INC 401K PLAN [EIN = 831282964]
• LOS ANGELES CITY LAW, A PROFESSIONAL CORPORATION 401K PL [EIN = 454910287]
• LOS ANGELES BUILDERS LLC [EIN = 834327781]
• LOS ANGELES LUNG CENTER, INC. RETIREMENT PLAN [EIN = 208203185]
• LOS ANGELES POULTRY INC. 401(K) PLAN [EIN = 954181336]
• LOS ANGELES LEGAL ADVOCATES 401(K) PLAN [EIN = 851380963]
• LOS ANGELES ALE WORKS, LLC 401(K) PLAN [EIN = 274400424]
• LOS ANGELES LUNG CENTER, INC. PENSION PLAN [EIN = 208203185]