401k Plan data: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN plan

CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN
Plan identification number	501

CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

CTBC BANK CORP. (USA) has sponsored the creation of one or more 401k plans.

Company Name: CTBC BANK CORP. (USA)

Employer identification number (EIN): 952368050

NAIC Classification: 522110
NAIC Description: Commercial Banking

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 PEARL LUU , SVP 2024-06-11 PEARL LUU , SVP 2024-06-11
501 2022-01-01 PEARL LUU , SVP 2023-07-06 PEARL LUU , SVP 2023-07-06
501 2021-01-01 PEARL LUU , SVP 2022-07-12 PEARL LUU , SVP 2022-07-12
501 2020-01-01 PEARL LUU , SVP 2021-07-14 PEARL LUU , SVP 2021-07-14
501 2019-01-01 PEARL LUU , SVP 2020-07-02 PEARL LUU , SVP 2020-07-02
501 2018-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01 SHARI LIN
501 2013-01-01 SHARI LIN
501 2012-01-01 SHARI LIN
501 2011-01-01 SHARI LIN
501 2009-01-01 SHARI LIN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-01-01	PEARL LUU , SVP	2024-06-11	PEARL LUU , SVP	2024-06-11
501	2022-01-01	PEARL LUU , SVP	2023-07-06	PEARL LUU , SVP	2023-07-06
501	2021-01-01	PEARL LUU , SVP	2022-07-12	PEARL LUU , SVP	2022-07-12
501	2020-01-01	PEARL LUU , SVP	2021-07-14	PEARL LUU , SVP	2021-07-14
501	2019-01-01	PEARL LUU , SVP	2020-07-02	PEARL LUU , SVP	2020-07-02
501	2018-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01	SHARI LIN
501	2013-01-01	SHARI LIN
501	2012-01-01	SHARI LIN
501	2011-01-01	SHARI LIN
501	2009-01-01	SHARI LIN

Plan Statistics for CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN

401k plan membership statisitcs for CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN

Measure Date Value
2023: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 363
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 497
Total of all active and inactive participants 2023-01-01 497
2022: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 340
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 363
Total of all active and inactive participants 2022-01-01 363
2021: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 326
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 340
Total of all active and inactive participants 2021-01-01 340
2020: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 325
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 326
Total of all active and inactive participants 2020-01-01 326
2019: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 316
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 325
Total of all active and inactive participants 2019-01-01 325
2018: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 307
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 316
Total of all active and inactive participants 2018-01-01 316
2017: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 306
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 306
Total of all active and inactive participants 2017-01-01 306
Total participants 2017-01-01 306
2016: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 902
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,011
Total of all active and inactive participants 2016-01-01 1,011
Total participants 2016-01-01 1,011
2015: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 909
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 902
Total of all active and inactive participants 2015-01-01 902
Total participants 2015-01-01 902
2014: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 247
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 909
Total of all active and inactive participants 2014-01-01 909
Total participants 2014-01-01 909
2013: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 276
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 247
Total of all active and inactive participants 2013-01-01 247
Total participants 2013-01-01 247
2012: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 274
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 276
Total of all active and inactive participants 2012-01-01 276
Total participants 2012-01-01 276
2011: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 292
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 269
Number of retired or separated participants receiving benefits 2011-01-01 5
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 274
2009: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 326
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 319
Number of retired or separated participants receiving benefits 2009-01-01 31
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 350

Measure	Date	Value
2023: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	363
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	497
Total of all active and inactive participants	2023-01-01	497
2022: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	340
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	363
Total of all active and inactive participants	2022-01-01	363
2021: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	326
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	340
Total of all active and inactive participants	2021-01-01	340
2020: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	325
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	326
Total of all active and inactive participants	2020-01-01	326
2019: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	316
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	325
Total of all active and inactive participants	2019-01-01	325
2018: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	307
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	316
Total of all active and inactive participants	2018-01-01	316
2017: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	306
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	306
Total of all active and inactive participants	2017-01-01	306
Total participants	2017-01-01	306
2016: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	902
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,011
Total of all active and inactive participants	2016-01-01	1,011
Total participants	2016-01-01	1,011
2015: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	909
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	902
Total of all active and inactive participants	2015-01-01	902
Total participants	2015-01-01	902
2014: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	247
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	909
Total of all active and inactive participants	2014-01-01	909
Total participants	2014-01-01	909
2013: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	276
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	247
Total of all active and inactive participants	2013-01-01	247
Total participants	2013-01-01	247
2012: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	274
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	276
Total of all active and inactive participants	2012-01-01	276
Total participants	2012-01-01	276
2011: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	292
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	269
Number of retired or separated participants receiving benefits	2011-01-01	5
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	274
2009: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	326
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	319
Number of retired or separated participants receiving benefits	2009-01-01	31
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	350

Form 5500 Responses for CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN

2023: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	First time form 5500 has been submitted	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	First time form 5500 has been submitted	Yes
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: CTBC BANK CORP. (USA) HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

21154

Policy instance

Insurance contract or identification number	21154
Number of Individuals Covered	273
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $19,768
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

231801

Policy instance

Insurance contract or identification number	231801
Number of Individuals Covered	231
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $60,119
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

VC371

Policy instance

Insurance contract or identification number	VC371
Number of Individuals Covered	35
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $4,453
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NR130

Policy instance

Insurance contract or identification number	NR130
Number of Individuals Covered	9
Total amount of commissions paid to insurance broker	USD $788
Total amount of fees paid to insurance company	USD $20
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

W0065532

Policy instance

Insurance contract or identification number	W0065532
Number of Individuals Covered	214
Total amount of commissions paid to insurance broker	USD $4,027
Total amount of fees paid to insurance company	USD $132,637
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

604268

Policy instance

Insurance contract or identification number	604268
Number of Individuals Covered	8
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,684
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

804099G

Policy instance

Insurance contract or identification number	804099G
Number of Individuals Covered	363
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,286
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

79394

Policy instance

Insurance contract or identification number	79394
Number of Individuals Covered	71
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,346
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

231801

Policy instance

Insurance contract or identification number	231801
Number of Individuals Covered	204
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $48,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,380
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

VC371

Policy instance

Insurance contract or identification number	VC371
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 $4,048
Total amount of fees paid to insurance company	USD $113
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,160
Amount paid for insurance broker fees	92
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NR130

Policy instance

Insurance contract or identification number	NR130
Number of Individuals Covered	14
Total amount of commissions paid to insurance broker	USD $1,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $302
Insurance broker organization code?	3

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

Policy contract number

W0065532

Policy instance

Insurance contract or identification number	W0065532
Number of Individuals Covered	222
Total amount of commissions paid to insurance broker	USD $3,727
Total amount of fees paid to insurance company	USD $126,179
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,727
Amount paid for insurance broker fees	126179
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

604268

Policy instance

Insurance contract or identification number	604268
Number of Individuals Covered	12
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,755
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

804099G

Policy instance

Insurance contract or identification number	804099G
Number of Individuals Covered	340
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,446
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,446
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

79394

Policy instance

Insurance contract or identification number	79394
Number of Individuals Covered	79
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,236
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $824
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

21154

Policy instance

Insurance contract or identification number	21154
Number of Individuals Covered	262
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $17,657
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,771
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

231801

Policy instance

Insurance contract or identification number	231801
Number of Individuals Covered	179
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $42,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,229
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

VC371

Policy instance

Insurance contract or identification number	VC371
Number of Individuals Covered	36
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,100
Total amount of fees paid to insurance company	USD $176
Commission paid to Insurance Broker	USD $1,759
Amount paid for insurance broker fees	109
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NR130

Policy instance

Insurance contract or identification number	NR130
Number of Individuals Covered	17
Total amount of commissions paid to insurance broker	USD $1,094
Total amount of fees paid to insurance company	USD $15
Commission paid to Insurance Broker	USD $355
Amount paid for insurance broker fees	8
Insurance broker organization code?	3

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

Policy contract number

W0065532

Policy instance

Insurance contract or identification number	W0065532
Number of Individuals Covered	230
Total amount of commissions paid to insurance broker	USD $3,548
Total amount of fees paid to insurance company	USD $115,518
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,548
Amount paid for insurance broker fees	115518
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

604268

Policy instance

Insurance contract or identification number	604268
Number of Individuals Covered	11
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,338
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

804099G

Policy instance

Insurance contract or identification number	804099G
Number of Individuals Covered	321
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $14,333
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,333
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

79394

Policy instance

Insurance contract or identification number	79394
Number of Individuals Covered	69
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,024
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $634
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

21154

Policy instance

Insurance contract or identification number	21154
Number of Individuals Covered	248
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $14,210
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,855
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

231801

Policy instance

Insurance contract or identification number	231801
Number of Individuals Covered	159
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $39,615
Commission paid to Insurance Broker	USD $30,031
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

VC371

Policy instance

Insurance contract or identification number	VC371
Number of Individuals Covered	42
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,753
Total amount of fees paid to insurance company	USD $459
Commission paid to Insurance Broker	USD $2,811
Amount paid for insurance broker fees	300
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NR130

Policy instance

Insurance contract or identification number	NR130
Number of Individuals Covered	15
Total amount of commissions paid to insurance broker	USD $1,881
Total amount of fees paid to insurance company	USD $227
Commission paid to Insurance Broker	USD $751
Amount paid for insurance broker fees	126
Insurance broker organization code?	3

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

Policy contract number

W0065532

Policy instance

Insurance contract or identification number	W0065532
Number of Individuals Covered	216
Total amount of commissions paid to insurance broker	USD $33,388
Total amount of fees paid to insurance company	USD $101,801
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $29,782
Amount paid for insurance broker fees	90336
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

604268

Policy instance

Insurance contract or identification number	604268
Number of Individuals Covered	11
Total amount of commissions paid to insurance broker	USD $4,046
Commission paid to Insurance Broker	USD $4,046
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

804099G

Policy instance

Insurance contract or identification number	804099G
Number of Individuals Covered	318
Total amount of commissions paid to insurance broker	USD $8,709
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $8,709
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

231801

Policy instance

Insurance contract or identification number	231801
Number of Individuals Covered	147
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $29,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,395
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

VC371

Policy instance

Insurance contract or identification number	VC371
Number of Individuals Covered	43
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,161
Total amount of fees paid to insurance company	USD $180
Other welfare benefits provided	SUPPLEMENTAL COVERAGE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,872
Amount paid for insurance broker fees	133
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NR130

Policy instance

Insurance contract or identification number	NR130
Number of Individuals Covered	16
Total amount of commissions paid to insurance broker	USD $2,535
Total amount of fees paid to insurance company	USD $28
Other welfare benefits provided	SUPPLEMENTAL COVERAGE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,079
Amount paid for insurance broker fees	17
Insurance broker organization code?	3

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

Policy contract number

W0065532

Policy instance

Insurance contract or identification number	W0065532
Number of Individuals Covered	220
Total amount of commissions paid to insurance broker	USD $33,345
Total amount of fees paid to insurance company	USD $98,612
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,102
Amount paid for insurance broker fees	49306
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

604268

Policy instance

Insurance contract or identification number	604268
Number of Individuals Covered	13
Total amount of commissions paid to insurance broker	USD $3,510
Commission paid to Insurance Broker	USD $1,781
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

0000024978

Policy instance

Insurance contract or identification number	0000024978
Number of Individuals Covered	37
Total amount of commissions paid to insurance broker	USD $7,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,421
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0804207

Policy instance

Insurance contract or identification number	0804207
Number of Individuals Covered	317
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,397
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,699
Insurance broker organization code?	3

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

Policy contract number

W0065532

Policy instance

Insurance contract or identification number	W0065532
Number of Individuals Covered	204
Total amount of commissions paid to insurance broker	USD $105,827
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,343
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NR130

Policy instance

Insurance contract or identification number	NR130
Total amount of commissions paid to insurance broker	USD $1,815
Total amount of fees paid to insurance company	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 $660
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

VC371

Policy instance

Insurance contract or identification number	VC371
Number of Individuals Covered	40
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,119
Total amount of fees paid to insurance company	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 $1,081
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

231801

Policy instance

Insurance contract or identification number	231801
Number of Individuals Covered	137
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $29,730
Total amount of fees paid to insurance company	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 $22,440
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0804207

Policy instance

Insurance contract or identification number	0804207
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 $14,614
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,307
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0804207

Policy instance

Insurance contract or identification number	0804207
Number of Individuals Covered	525
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $52,490
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Commission paid to Insurance Broker	USD $26,245
Insurance broker organization code?	3
Insurance broker name	SANDRA LEE KAWANO

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95234 )

Policy contract number

0804207HNO

Policy instance

Insurance contract or identification number	0804207HNO
Number of Individuals Covered	308
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $55,044
Commission paid to Insurance Broker	USD $27,522
Insurance broker organization code?	3
Insurance broker name	HING AND ASSOCIATES INSURANCE

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

231801

Policy instance

Insurance contract or identification number	231801
Number of Individuals Covered	116
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $25,510
Commission paid to Insurance Broker	USD $12,755
Insurance broker organization code?	3
Insurance broker name	HING AND ASSOCIATES INSURANCE

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

VC371

Policy instance

Insurance contract or identification number	VC371
Number of Individuals Covered	31
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,560
Total amount of fees paid to insurance company	USD $77
Other welfare benefits provided	SUPPLEMENTAL COVERAGE
Commission paid to Insurance Broker	USD $690
Insurance broker organization code?	3
Amount paid for insurance broker fees	14
Insurance broker name	DALE I DAVIS

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

604268

Policy instance

Insurance contract or identification number	604268
Number of Individuals Covered	10
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,107
Commission paid to Insurance Broker	USD $2,107
Insurance broker organization code?	3
Insurance broker name	HING & ASSOCIATES INS BROKERS

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NR130

Policy instance

Insurance contract or identification number	NR130
Number of Individuals Covered	19
Total amount of commissions paid to insurance broker	USD $1,682
Total amount of fees paid to insurance company	USD $50
Other welfare benefits provided	SUPPLEMENTAL COVERAGE
Commission paid to Insurance Broker	USD $560
Amount paid for insurance broker fees	25
Insurance broker organization code?	3
Insurance broker name	TIMOTHY C CAVAZOS

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95234 )

Policy contract number

0804207HNO

Policy instance

Insurance contract or identification number	0804207HNO
Number of Individuals Covered	298
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $51,227
Total amount of fees paid to insurance company	USD $863
Welfare Benefit Premiums Paid to Carrier	USD $1,261,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,613
Amount paid for insurance broker fees	863
Additional information about fees paid to insurance broker	PM CROSS SALE
Insurance broker organization code?	3
Insurance broker name	SANDRA LEE KAWANO

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

231801

Policy instance

Insurance contract or identification number	231801
Number of Individuals Covered	80
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $15,541
Welfare Benefit Premiums Paid to Carrier	USD $392,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,771
Insurance broker organization code?	3
Insurance broker name	HAROLD L. LEE & SONS, INC.

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

VC371

Policy instance

Insurance contract or identification number	VC371
Number of Individuals Covered	44
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,518
Total amount of fees paid to insurance company	USD $64
Welfare Benefit Premiums Paid to Carrier	USD $36,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,022
Insurance broker organization code?	3
Amount paid for insurance broker fees	26
Insurance broker name	TERRANCE M LUCZAJ

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

604268

Policy instance

Insurance contract or identification number	604268
Number of Individuals Covered	6
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $951
Welfare Benefit Premiums Paid to Carrier	USD $21,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $951
Insurance broker organization code?	3
Insurance broker name	HING AND ASSOCIATES INS BROKERS INC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0804207

Policy instance

Insurance contract or identification number	0804207
Number of Individuals Covered	902
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $46,190
Total amount of fees paid to insurance company	USD $536
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $994,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,095
Insurance broker organization code?	3
Amount paid for insurance broker fees	536
Additional information about fees paid to insurance broker	PM CROSS SALE
Insurance broker name	HING AND ASSOCIATES INSURANCE

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0804207

Policy instance

Insurance contract or identification number	0804207
Number of Individuals Covered	909
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $54,754
Total amount of fees paid to insurance company	USD $5,700
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH-DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $944,373
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,377
Amount paid for insurance broker fees	2850
Additional information about fees paid to insurance broker	PM CROSS SALE
Insurance broker organization code?	3
Insurance broker name	HING AND ASSOCIATES INSURANCE

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95234 )

Policy contract number

0804207HNO

Policy instance

Insurance contract or identification number	0804207HNO
Number of Individuals Covered	317
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $56,896
Total amount of fees paid to insurance company	USD $14,059
Welfare Benefit Premiums Paid to Carrier	USD $1,238,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,448
Amount paid for insurance broker fees	9792
Additional information about fees paid to insurance broker	PM CROSS SALE & WEST JANUARY MEDICAL SUPERBONUS
Insurance broker organization code?	3
Insurance broker name	SANDRA LEE KAWANO

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

231801

Policy instance

Insurance contract or identification number	231801
Number of Individuals Covered	58
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,336
Welfare Benefit Premiums Paid to Carrier	USD $268,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,168
Insurance broker organization code?	3
Insurance broker name	HAROLD L. LEE & SONS, INC.

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NR130

Policy instance

Insurance contract or identification number	NR130
Number of Individuals Covered	16
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,422
Welfare Benefit Premiums Paid to Carrier	USD $8,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,477
Insurance broker organization code?	3
Insurance broker name	TODD V MASON

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

246679400

Policy instance

Insurance contract or identification number	246679400
Number of Individuals Covered	245
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,996
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
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 $69,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,996
Insurance broker organization code?	3
Insurance broker name	HAROLD LEE AND SONS

BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )

Policy contract number

F32801

Policy instance

Insurance contract or identification number	F32801
Number of Individuals Covered	246
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,587
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $39,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,293
Insurance broker organization code?	3
Insurance broker name	HING AND ASSOCIATES INSURANCE

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

Policy contract number

PD7133, H55650

Policy instance

Insurance contract or identification number	PD7133, H55650
Number of Individuals Covered	247
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $146,640
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,652,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,104
Insurance broker organization code?	3
Insurance broker name	SANDRA L. KAWANO

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

Policy contract number

PD7133,H55650

Policy instance

Insurance contract or identification number	PD7133,H55650
Number of Individuals Covered	263
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $111,644
Total amount of fees paid to insurance company	USD $21,590
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,143,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,641
Amount paid for insurance broker fees	10795
Additional information about fees paid to insurance broker	BONUS OVERRIDE ALLOCATION
Insurance broker organization code?	3
Insurance broker name	CENTERSTONE INSURANCE

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

246-6794-00

Policy instance

Insurance contract or identification number	246-6794-00
Number of Individuals Covered	276
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,994
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $61,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,994
Insurance broker organization code?	3
Insurance broker name	HAROLD LEE & SONS

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

246-6794-00

Policy instance

Insurance contract or identification number	246-6794-00
Number of Individuals Covered	252
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,496
Total amount of fees paid to insurance company	USD $2,889
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $52,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

227682

Policy instance

Insurance contract or identification number	227682
Number of Individuals Covered	65
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $11,400
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $224,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

30002338

Policy instance

Insurance contract or identification number	30002338
Number of Individuals Covered	265
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,691
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $42,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

CB2235

Policy instance

Insurance contract or identification number	CB2235
Number of Individuals Covered	68
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $13,629
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $456,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

N4486/76041

Policy instance

Insurance contract or identification number	N4486/76041
Number of Individuals Covered	168
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $57,677
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,496,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00453445

Policy instance

Insurance contract or identification number	00453445
Number of Individuals Covered	256
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,271
Total amount of fees paid to insurance company	USD $2,525
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $243,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00453445

Policy instance

Insurance contract or identification number	00453445
Number of Individuals Covered	264
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,520
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $193,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,520
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

227682

Policy instance

Insurance contract or identification number	227682
Number of Individuals Covered	52
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,269
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	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 $144,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,752
Insurance broker organization code?	3
Insurance broker name	PENSION & BENEFIT INSURANCE SERVICE

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

CB2235

Policy instance

Insurance contract or identification number	CB2235
Number of Individuals Covered	79
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $15,224
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $492,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,224
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )

Policy contract number

60016266

Policy instance

Insurance contract or identification number	60016266
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $12,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

30002338

Policy instance

Insurance contract or identification number	30002338
Number of Individuals Covered	269
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,764
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $45,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,764
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

246-6794-00

Policy instance

Insurance contract or identification number	246-6794-00
Number of Individuals Covered	260
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,354
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $60,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,354
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

N4486/76041

Policy instance

Insurance contract or identification number	N4486/76041
Number of Individuals Covered	186
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $41,361
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,384,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,361
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

Potentially related plans

CTBC BANK CORP. (USA) 401(K) PROFIT SHARING PLAN [EIN = 521644565]

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Company Name:	CTBC BANK CORP. (USA)
Employer identification number (EIN):	952368050
NAIC Classification:	522110
NAIC Description:	Commercial Banking