401k Plan data: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN plan

LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN
Plan identification number	501

LOS ANGELES CHILD GUIDANCE CLINIC 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 Other welfare benefit cover

401k Sponsoring company profile

WELLNEST EMOTIONAL HEALTH AND WELLNESS has sponsored the creation of one or more 401k plans.

Company Name: WELLNEST EMOTIONAL HEALTH AND WELLNESS

Employer identification number (EIN): 951690974

NAIC Classification: 621420
NAIC Description: Outpatient Mental Health and Substance Abuse Centers

Additional information about WELLNEST EMOTIONAL HEALTH AND WELLNESS

Jurisdiction of Incorporation: California Department of State

Incorporation Date: 0000-00-00

Company Identification Number: C0200170

Legal Registered Office Address: 3031 South Vermont AvenueLos AngelesCA90007

United States of America (USA)

More information about WELLNEST EMOTIONAL HEALTH AND WELLNESS

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LOS ANGELES CHILD GUIDANCE CLINIC 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
501 2019-01-01
501 2018-01-01
501 2017-01-01 SUSAN WHITNEY
501 2016-01-01 SUSAN WHITNEY

Plan Statistics for LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN

Measure Date Value
2022: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 244
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 229
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 2022-01-01 230
2021: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 233
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 235
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 2021-01-01 237
2020: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 244
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 223
Number of retired or separated participants receiving benefits 2020-01-01 2
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 225
2019: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 284
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 290
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 290
2018: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 282
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 226
Number of retired or separated participants receiving benefits 2018-01-01 2
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 228
2017: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 302
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 282
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 282
2016: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 262
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 294
Number of retired or separated participants receiving benefits 2016-01-01 8
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 302

Measure	Date	Value
2022: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	244
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	229
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	230
2021: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	233
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	235
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	237
2020: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	244
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	223
Number of retired or separated participants receiving benefits	2020-01-01	2
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	225
2019: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	284
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	290
Number of retired or separated participants receiving benefits	2019-01-01	0
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	290
2018: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	282
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	226
Number of retired or separated participants receiving benefits	2018-01-01	2
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	228
2017: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	302
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	282
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	282
2016: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	262
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	294
Number of retired or separated participants receiving benefits	2016-01-01	8
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	302

Form 5500 Responses for LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN

2022: LOS ANGELES CHILD GUIDANCE CLINIC 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 CHILD GUIDANCE CLINIC 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 funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: LOS ANGELES CHILD GUIDANCE CLINIC 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 benefit arrangement – Insurance	Yes
2018: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: LOS ANGELES CHILD GUIDANCE CLINIC HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK966428

Policy instance

Insurance contract or identification number	LK966428
Number of Individuals Covered	71
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,070
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	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 $20,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,070
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

233004

Policy instance

Insurance contract or identification number	233004
Number of Individuals Covered	178
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $66,003
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $1,432,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66,003
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

W0067795

Policy instance

Insurance contract or identification number	W0067795
Number of Individuals Covered	74
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $25,067
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 $476,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	25067
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX969702

Policy instance

Insurance contract or identification number	FLX969702
Number of Individuals Covered	258
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,745
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE
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 $31,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,745
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

CI 961653

Policy instance

Insurance contract or identification number	CI 961653
Number of Individuals Covered	31
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,371
Total amount of fees paid to insurance company	USD $11
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	VOLUNTARY 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 $9,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,371
Amount paid for insurance broker fees	11
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

AI961734

Policy instance

Insurance contract or identification number	AI961734
Number of Individuals Covered	34
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,327
Total amount of fees paid to insurance company	USD $5
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL INJURY
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 $8,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,327
Amount paid for insurance broker fees	5
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK971137

Policy instance

Insurance contract or identification number	OK971137
Number of Individuals Covered	258
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,258
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	AD&D, VOLUNTARY AD&D
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 $8,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,258
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

10206741001

Policy instance

Insurance contract or identification number	10206741001
Number of Individuals Covered	233
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,802
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 $19,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,802
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

10206751001

Policy instance

Insurance contract or identification number	10206751001
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 $32
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 $242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3344106

Policy instance

Insurance contract or identification number	3344106
Number of Individuals Covered	124
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $11,580
Total amount of fees paid to insurance company	USD $955
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 $116,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,580
Amount paid for insurance broker fees	955
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker organization code?	3

CIGNA DENTAL HEALTH OF CALIFORNIA,INC (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

3344106

Policy instance

Insurance contract or identification number	3344106
Number of Individuals Covered	76
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,574
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 $15,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,574
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

AI961734

Policy instance

Insurance contract or identification number	AI961734
Number of Individuals Covered	60
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,245
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL INJURY
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 $8,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,245
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

CI 961653

Policy instance

Insurance contract or identification number	CI 961653
Number of Individuals Covered	30
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,082
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	VOLUNTARY 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 $7,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,082
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX969702

Policy instance

Insurance contract or identification number	FLX969702
Number of Individuals Covered	235
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,822
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE
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 $25,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,822
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK966428

Policy instance

Insurance contract or identification number	LK966428
Number of Individuals Covered	66
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,456
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	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 $16,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,456
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

233004

Policy instance

Insurance contract or identification number	233004
Number of Individuals Covered	182
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $62,827
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 $1,266,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,827
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK971137

Policy instance

Insurance contract or identification number	OK971137
Number of Individuals Covered	235
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $877
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	AD&D, VOLUNTARY AD&D
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 $5,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $877
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

10206741001

Policy instance

Insurance contract or identification number	10206741001
Number of Individuals Covered	247
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,297
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 $9,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,297
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

W0067795

Policy instance

Insurance contract or identification number	W0067795
Number of Individuals Covered	73
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $23,165
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 $440,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	23165
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

CIGNA DENTAL HEALTH OF CALIFORNIA,INC (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

3344106

Policy instance

Insurance contract or identification number	3344106
Number of Individuals Covered	82
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,139
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 $11,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,139
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3344106

Policy instance

Insurance contract or identification number	3344106
Number of Individuals Covered	122
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,927
Total amount of fees paid to insurance company	USD $1,524
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 $70,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,927
Amount paid for insurance broker fees	1524
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker organization code?	3

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

Policy contract number

10206751001

Policy instance

Insurance contract or identification number	10206751001
Number of Individuals Covered	2
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2
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 $30
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
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

233004

Policy instance

Insurance contract or identification number	233004
Number of Individuals Covered	173
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $56,751
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 $1,144,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,751
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

10206751001

Policy instance

Insurance contract or identification number	10206751001
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1
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 $0
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
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

10206741001

Policy instance

Insurance contract or identification number	10206741001
Number of Individuals Covered	247
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,245
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 $21,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,245
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BHST

Policy instance

Insurance contract or identification number	GVTL0BHST
Number of Individuals Covered	68
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,735
Total amount of fees paid to insurance company	USD $1,746
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	VOLUNTARY TERM LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,735
Amount paid for insurance broker fees	246
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

GUPR0BHST

Policy instance

Insurance contract or identification number	GUPR0BHST
Number of Individuals Covered	30
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,346
Total amount of fees paid to insurance company	USD $1,660
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 $10,360
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,346
Amount paid for insurance broker fees	160
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

GUDH0BHST

Policy instance

Insurance contract or identification number	GUDH0BHST
Number of Individuals Covered	48
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,664
Total amount of fees paid to insurance company	USD $162
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	VOLUNTARY 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 $11,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,664
Amount paid for insurance broker fees	162
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

GUDE0BHST

Policy instance

Insurance contract or identification number	GUDE0BHST
Number of Individuals Covered	36
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,437
Total amount of fees paid to insurance company	USD $119
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	VOLUNTARY 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 $10,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,437
Amount paid for insurance broker fees	119
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

GLUG0BHST

Policy instance

Insurance contract or identification number	GLUG0BHST
Number of Individuals Covered	223
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,624
Total amount of fees paid to insurance company	USD $114
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	AD&D
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 $11,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,624
Amount paid for insurance broker fees	114
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

GLTD0BHST

Policy instance

Insurance contract or identification number	GLTD0BHST
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 $2,125
Total amount of fees paid to insurance company	USD $187
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 $15,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,125
Amount paid for insurance broker fees	187
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

556750

Policy instance

Insurance contract or identification number	556750
Number of Individuals Covered	202
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $12,517
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	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 $125,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,517
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

W0067795

Policy instance

Insurance contract or identification number	W0067795
Number of Individuals Covered	74
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $22,192
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 $418,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	22192
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0BHST

Policy instance

Insurance contract or identification number	GUDH0BHST
Number of Individuals Covered	62
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,369
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	VOLUNTARY 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 $15,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,369
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0BHST

Policy instance

Insurance contract or identification number	GUDE0BHST
Number of Individuals Covered	41
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,797
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	VOLUNTARY 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 $11,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,797
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BHST

Policy instance

Insurance contract or identification number	GLUG0BHST
Number of Individuals Covered	235
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,681
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 $11,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,681
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BHST

Policy instance

Insurance contract or identification number	GLTD0BHST
Number of Individuals Covered	39
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,583
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	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 $17,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,583
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

556750

Policy instance

Insurance contract or identification number	556750
Number of Individuals Covered	203
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,609
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 $116,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,609
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

W0067795

Policy instance

Insurance contract or identification number	W0067795
Number of Individuals Covered	84
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $21,779
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 $413,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	21779
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

233004

Policy instance

Insurance contract or identification number	233004
Number of Individuals Covered	163
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $52,756
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 $1,026,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,756
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPR0BHST

Policy instance

Insurance contract or identification number	GUPR0BHST
Number of Individuals Covered	39
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,154
Total amount of fees paid to insurance company	USD $1,500
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 $12,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,154
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BHST

Policy instance

Insurance contract or identification number	GVTL0BHST
Number of Individuals Covered	79
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,714
Total amount of fees paid to insurance company	USD $1,500
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	VOLUNTARY TERM LIFE
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 $22,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,714
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

10206741001

Policy instance

Insurance contract or identification number	10206741001
Number of Individuals Covered	237
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,425
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 $19,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,425
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

10206751001

Policy instance

Insurance contract or identification number	10206751001
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2
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 $15
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
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

575549

Policy instance

Insurance contract or identification number	575549
Number of Individuals Covered	21
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,159
Total amount of fees paid to insurance company	USD $109
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 $19,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,159
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

506224

Policy instance

Insurance contract or identification number	506224
Number of Individuals Covered	59
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,939
Total amount of fees paid to insurance company	USD $44
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	LIFESTYLE LIFE
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 $18,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,034
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

CALIFORNIA DENTAL NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

003007

Policy instance

Insurance contract or identification number	003007
Number of Individuals Covered	39
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $962
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 $9,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $574
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

1060833

Policy instance

Insurance contract or identification number	1060833
Number of Individuals Covered	275
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,627
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	Yes
Life Insurance Welfare Benefit	Yes
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 $132,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,776
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

002586

Policy instance

Insurance contract or identification number	002586
Number of Individuals Covered	227
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $638
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $374
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

233004

Policy instance

Insurance contract or identification number	233004
Number of Individuals Covered	221
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $63,542
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 $1,375,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,678
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

CALIFORNIA DENTAL NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

003007

Policy instance

Insurance contract or identification number	003007
Number of Individuals Covered	45
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $810
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 $8,101
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $810
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	CLINTON POLLEY INS BROKERS

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

Policy contract number

1060833

Policy instance

Insurance contract or identification number	1060833
Number of Individuals Covered	282
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,547
Total amount of fees paid to insurance company	USD $1,808
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	Yes
Life Insurance Welfare Benefit	Yes
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 $137,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,547
Amount paid for insurance broker fees	1808
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	CLINTON POLLEY GROUP

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

Policy contract number

002586

Policy instance

Insurance contract or identification number	002586
Number of Individuals Covered	210
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $620
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	EAP
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 $6,199
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $620
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMISSIONS
Insurance broker organization code?	3
Insurance broker name	CLINTON POLLEY GROUP

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

Policy contract number

233004

Policy instance

Insurance contract or identification number	233004
Number of Individuals Covered	224
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $62,969
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 $1,153,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,969
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	CLINTON POLLEY GROUP

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Company Name:	WELLNEST EMOTIONAL HEALTH AND WELLNESS
Employer identification number (EIN):	951690974
NAIC Classification:	621420
NAIC Description:	Outpatient Mental Health and Substance Abuse Centers

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:	0000-00-00
Company Identification Number:	C0200170
Legal Registered Office Address:	3031 South Vermont AvenueLos AngelesCA90007 United States of America (USA)