ERNIE BALL, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ERNIE BALL INC GROUP LIFE AND HEALTH PLAN
| Measure | Date | Value |
|---|
| 2022: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 368 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 349 |
| Total of all active and inactive participants | 2022-01-01 | 349 |
| 2021: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 355 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 368 |
| Total of all active and inactive participants | 2021-01-01 | 368 |
| 2020: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 411 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 355 |
| Total of all active and inactive participants | 2020-01-01 | 355 |
| 2019: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 394 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 411 |
| Total of all active and inactive participants | 2019-01-01 | 411 |
| 2018: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 369 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 394 |
| Total of all active and inactive participants | 2018-01-01 | 394 |
| 2017: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 460 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 369 |
| Total of all active and inactive participants | 2017-01-01 | 369 |
| 2016: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 326 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 460 |
| Total of all active and inactive participants | 2016-01-01 | 460 |
| 2015: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 385 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 326 |
| Total of all active and inactive participants | 2015-01-01 | 326 |
| 2014: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 239 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 385 |
| Total of all active and inactive participants | 2014-01-01 | 385 |
| 2013: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 180 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 239 |
| Total of all active and inactive participants | 2013-01-01 | 239 |
| 2012: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 180 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 180 |
| Total of all active and inactive participants | 2012-01-01 | 180 |
| 2011: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 320 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 320 |
| Total of all active and inactive participants | 2011-01-01 | 320 |
| 2010: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 285 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 320 |
| Total of all active and inactive participants | 2010-01-01 | 320 |
| 2009: ERNIE BALL INC GROUP LIFE AND HEALTH PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 292 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 285 |
| Total of all active and inactive participants | 2009-01-01 | 285 |
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | MRA44 |
| Policy instance | 2 |
| Insurance contract or identification number | MRA44 | | 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 $2,043 | | Total amount of fees paid to insurance company | USD $20 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,170 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $779 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 1 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $35,481 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $712,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,972 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 280977 |
| Policy instance | 3 |
| Insurance contract or identification number | 280977 | | Number of Individuals Covered | 349 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $62,977 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,480,408 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52,738 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 26454 |
| Policy instance | 4 |
| Insurance contract or identification number | 26454 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,389 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $220,576 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $796 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 1 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $34,362 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $699,055 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,362 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | MRA44 |
| Policy instance | 2 |
| Insurance contract or identification number | MRA44 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,679 | | Total amount of fees paid to insurance company | USD $434 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,330 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,028 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 26454 |
| Policy instance | 4 |
| Insurance contract or identification number | 26454 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,593 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,738 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,459 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 280977 |
| Policy instance | 3 |
| Insurance contract or identification number | 280977 | | Number of Individuals Covered | 368 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $56,060 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,334,894 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,060 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 280977 |
| Policy instance | 3 |
| Insurance contract or identification number | 280977 | | Number of Individuals Covered | 355 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $61,937 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,323,614 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,937 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 82-2723296 |
| Policy instance | 2 |
| Insurance contract or identification number | 82-2723296 | | Number of Individuals Covered | 66 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $19,661 | | Total amount of fees paid to insurance company | USD $420 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,907 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,026 | | Amount paid for insurance broker fees | 420 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 1 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $30,159 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $603,360 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,159 | | 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 | R0715235 |
| Policy instance | 4 |
| Insurance contract or identification number | R0715235 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,648 | | Total amount of fees paid to insurance company | USD $159 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,191 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,648 | | Amount paid for insurance broker fees | 159 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 280977 |
| Policy instance | 3 |
| Insurance contract or identification number | 280977 | | Number of Individuals Covered | 411 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $60,153 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,408,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,153 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 2 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $27,458 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $546,984 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,458 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0011682579 |
| Policy instance | 1 |
| Insurance contract or identification number | 0011682579 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,580 | | Total amount of fees paid to insurance company | USD $164 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,371 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,580 | | Amount paid for insurance broker fees | 90 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 2 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $28,626 | | Total amount of fees paid to insurance company | USD $4 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $534,395 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,626 | | Amount paid for insurance broker fees | 4 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 608776 |
| Policy instance | 5 |
| Insurance contract or identification number | 608776 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,128 | | Total amount of fees paid to insurance company | USD $524 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFESTYLE | | Welfare Benefit Premiums Paid to Carrier | USD $27,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,128 | | Amount paid for insurance broker fees | 524 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 280977 |
| Policy instance | 3 |
| Insurance contract or identification number | 280977 | | Number of Individuals Covered | 394 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $48,613 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,267,464 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,936 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 001682579 |
| Policy instance | 1 |
| Insurance contract or identification number | 001682579 | | Number of Individuals Covered | 66 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,750 | | Total amount of fees paid to insurance company | USD $475 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,193 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,750 | | Amount paid for insurance broker fees | 316 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 0011682579 |
| Policy instance | 4 |
| Insurance contract or identification number | 0011682579 | | 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 $9,410 | | Total amount of fees paid to insurance company | USD $842 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,114 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,410 | | Amount paid for insurance broker fees | 842 | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | AG497 |
| Policy instance | 1 |
| Insurance contract or identification number | AG497 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $6,451 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER, CRITICAL ILLNESS, UNIV LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $89,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,392 | | Insurance broker organization code? | 3 | | Insurance broker name | JETRENEE C. CHAPMAN |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 2 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $21,287 | | Total amount of fees paid to insurance company | USD $8 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $465,366 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,287 | | Amount paid for insurance broker fees | 8 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS, LLC |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 280977 |
| Policy instance | 3 |
| Insurance contract or identification number | 280977 | | Number of Individuals Covered | 369 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $40,756 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,038,120 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $40,756 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS, LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 4 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $27,983 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $518,106 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,983 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00606321 |
| Policy instance | 3 |
| Insurance contract or identification number | 00606321 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $37,560 | | Total amount of fees paid to insurance company | USD $13,733 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $311,940 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,560 | | Amount paid for insurance broker fees | 13733 | | Additional information about fees paid to insurance broker | DIRECT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | AG497 |
| Policy instance | 2 |
| Insurance contract or identification number | AG497 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $7,965 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,710 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGAR V AGUILAR |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05576303 |
| Policy instance | 1 |
| Insurance contract or identification number | KM05576303 | | Number of Individuals Covered | 326 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $7,060 | | Total amount of fees paid to insurance company | USD $1,387 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $135,832 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,060 | | Amount paid for insurance broker fees | 1387 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
|
| SAFEGUARD HEALTH PLANS INC (National Association of Insurance Commissioners NAIC id number: 79014 ) |
| Policy contract number | 97310471 |
| Policy instance | 5 |
| Insurance contract or identification number | 97310471 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,632 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,896 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,632 | | Amount paid for insurance broker fees | 0 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00606321 |
| Policy instance | 3 |
| Insurance contract or identification number | 00606321 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $55,490 | | Total amount of fees paid to insurance company | USD $1,216 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $439,594 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $55,490 | | Amount paid for insurance broker fees | 1216 | | Additional information about fees paid to insurance broker | DIRECT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | AG497 |
| Policy instance | 2 |
| Insurance contract or identification number | AG497 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,473 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,379 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $841 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGAR V AGUILAR |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05576303 |
| Policy instance | 1 |
| Insurance contract or identification number | KM05576303 | | Number of Individuals Covered | 385 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $4,690 | | Total amount of fees paid to insurance company | USD $100 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $121,491 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,690 | | Amount paid for insurance broker fees | 100 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 4 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $23,235 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $507,722 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,235 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 606321 |
| Policy instance | 3 |
| Insurance contract or identification number | 606321 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $54,971 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $526,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,971 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05576303 |
| Policy instance | 1 |
| Insurance contract or identification number | KM05576303 | | Number of Individuals Covered | 399 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $4,805 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $127,294 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,805 | | Insurance broker organization code? | 3 | | Insurance broker name | |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G#4049779 |
| Policy instance | 2 |
| Insurance contract or identification number | G#4049779 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $267 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $2,732 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $267 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 4 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 129 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $25,709 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $449,775 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,709 | | Insurance broker organization code? | 3 | | Insurance broker name | |
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| SAFEGUARD HEALTH PLANS INC (National Association of Insurance Commissioners NAIC id number: 79014 ) |
| Policy contract number | 97310471 |
| Policy instance | 5 |
| Insurance contract or identification number | 97310471 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $1,743 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,743 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G#4049779 |
| Policy instance | 2 |
| Insurance contract or identification number | G#4049779 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $1,027 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,335 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,027 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 606321 |
| Policy instance | 3 |
| Insurance contract or identification number | 606321 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $50,850 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $545,147 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50,850 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 4 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $18,217 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $402,609 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,217 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05576303 |
| Policy instance | 1 |
| Insurance contract or identification number | KM05576303 | | Number of Individuals Covered | 370 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $3,466 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,603 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,466 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G#4049779 |
| Policy instance | 3 |
| Insurance contract or identification number | G#4049779 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $909 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $9,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 151260 |
| Policy instance | 1 |
| Insurance contract or identification number | 151260 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $4,694 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $-1,356 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05576303 |
| Policy instance | 2 |
| Insurance contract or identification number | KM05576303 | | Number of Individuals Covered | 320 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $3,286 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,199 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 606321 |
| Policy instance | 4 |
| Insurance contract or identification number | 606321 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $53,717 | | Total amount of fees paid to insurance company | USD $1,000 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $500,758 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05576303 |
| Policy instance | 2 |
| Insurance contract or identification number | KM05576303 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2009-04-01 | | Insurance policy end date | 2010-03-31 | | Total amount of commissions paid to insurance broker | USD $3,214 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $88,539 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,214 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G#4049779 |
| Policy instance | 3 |
| Insurance contract or identification number | G#4049779 | | Number of Individuals Covered | 220 | | Insurance policy start date | 2009-04-01 | | Insurance policy end date | 2010-03-31 | | Total amount of commissions paid to insurance broker | USD $862 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $8,628 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $862 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 230289 |
| Policy instance | 4 |
| Insurance contract or identification number | 230289 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $7,994 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $159,294 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,994 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 151260 |
| Policy instance | 1 |
| Insurance contract or identification number | 151260 | | Number of Individuals Covered | 273 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $55,082 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,114,505 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $55,082 | | Insurance broker organization code? | 3 | | Insurance broker name | DIBUDUO & DEFENDIS INS BROKERS LLC |
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