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1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN
Plan identification number 501

1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

MEL BERNIE AND COMPANY has sponsored the creation of one or more 401k plans.

Company Name:MEL BERNIE AND COMPANY
Employer identification number (EIN):952628565
NAIC Classification:423940
NAIC Description:Jewelry, Watch, Precious Stone, and Precious Metal Merchant Wholesalers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012015-06-01GARY ARIAN
5012015-06-01GARY C. ARIAN2018-12-07
5012014-06-01GARY C ARIAN
5012013-06-01GARY ARIAN
5012012-06-01MEL BERNIE
5012011-06-01PAUL EDMEIER
5012009-06-01PAUL EDMEIER

Plan Statistics for 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN

Measure Date Value
2015: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-06-01128
Total number of active participants reported on line 7a of the Form 55002015-06-01128
Number of retired or separated participants receiving benefits2015-06-010
Number of other retired or separated participants entitled to future benefits2015-06-010
Total of all active and inactive participants2015-06-01128
2014: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-06-01128
Total number of active participants reported on line 7a of the Form 55002014-06-01128
Number of retired or separated participants receiving benefits2014-06-010
Number of other retired or separated participants entitled to future benefits2014-06-010
Total of all active and inactive participants2014-06-01128
2013: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-06-01140
Total number of active participants reported on line 7a of the Form 55002013-06-01128
Number of retired or separated participants receiving benefits2013-06-010
Number of other retired or separated participants entitled to future benefits2013-06-010
Total of all active and inactive participants2013-06-01128
2012: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-06-01134
Total number of active participants reported on line 7a of the Form 55002012-06-01140
Total of all active and inactive participants2012-06-01140
Total participants2012-06-010
2011: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-06-01130
Total number of active participants reported on line 7a of the Form 55002011-06-01134
Total of all active and inactive participants2011-06-01134
Total participants2011-06-01134
2009: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-06-01138
Total number of active participants reported on line 7a of the Form 55002009-06-01141
Total of all active and inactive participants2009-06-01141
Total participants2009-06-01141

Form 5500 Responses for 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN

2015: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01Submission has been amendedNo
2015-06-01This submission is the final filingNo
2015-06-01This return/report is a short plan year return/report (less than 12 months)No
2015-06-01Plan is a collectively bargained planNo
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – InsuranceYes
2014: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-06-01Type of plan entitySingle employer plan
2014-06-01Submission has been amendedNo
2014-06-01This submission is the final filingNo
2014-06-01This return/report is a short plan year return/report (less than 12 months)No
2014-06-01Plan is a collectively bargained planNo
2014-06-01Plan funding arrangement – InsuranceYes
2014-06-01Plan benefit arrangement – InsuranceYes
2013: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-06-01Type of plan entitySingle employer plan
2013-06-01Submission has been amendedNo
2013-06-01This submission is the final filingNo
2013-06-01This return/report is a short plan year return/report (less than 12 months)No
2013-06-01Plan is a collectively bargained planNo
2013-06-01Plan funding arrangement – InsuranceYes
2013-06-01Plan benefit arrangement – InsuranceYes
2012: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-06-01Type of plan entitySingle employer plan
2012-06-01Plan funding arrangement – InsuranceYes
2012-06-01Plan benefit arrangement – InsuranceYes
2011: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-06-01Type of plan entitySingle employer plan
2011-06-01Plan funding arrangement – InsuranceYes
2011-06-01Plan benefit arrangement – InsuranceYes
2009: 1928 JEWELRY COMPANY EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-06-01Type of plan entitySingle employer plan
2009-06-01Plan funding arrangement – InsuranceYes
2009-06-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605249
Policy instance 3
Insurance contract or identification numberSGM605249
Number of Individuals Covered38
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $2,644
Total amount of fees paid to insurance companyUSD $774
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,644
Amount paid for insurance broker fees774
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3337988
Policy instance 2
Insurance contract or identification number3337988
Number of Individuals Covered36
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $3,372
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $33,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,372
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberMG856A
Policy instance 1
Insurance contract or identification numberMG856A
Number of Individuals Covered38
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $9,556
Total amount of fees paid to insurance companyUSD $1,424
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $250,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,556
Amount paid for insurance broker fees1424
Additional information about fees paid to insurance brokerBONUS MISCELLANEOUS COMPENSATION
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605249
Policy instance 3
Insurance contract or identification numberSGM605249
Number of Individuals Covered128
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $2,636
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,636
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberS4181A
Policy instance 1
Insurance contract or identification numberS4181A
Number of Individuals Covered45
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $10,626
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $270,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,626
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3337988
Policy instance 2
Insurance contract or identification number3337988
Number of Individuals Covered40
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $3,068
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $30,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,068
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number9516264
Policy instance 4
Insurance contract or identification number9516264
Number of Individuals Covered36
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $668
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT
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 CarrierUSD $5,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $668
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225504
Policy instance 1
Insurance contract or identification number225504
Number of Individuals Covered58
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $14,133
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $368,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,075
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5458643
Policy instance 2
Insurance contract or identification number5458643
Number of Individuals Covered21
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $2,102
Total amount of fees paid to insurance companyUSD $66
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $21,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,951
Insurance broker organization code?3
Amount paid for insurance broker fees66
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
Insurance broker nameJ.D. GILMOUR AND COMPANY, INC.
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number5458643
Policy instance 3
Insurance contract or identification number5458643
Number of Individuals Covered18
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $385
Total amount of fees paid to insurance companyUSD $12
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $3,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $355
Insurance broker organization code?3
Amount paid for insurance broker fees12
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
Insurance broker nameJ.D. GILMOUR AND COMPANY, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12261558
Policy instance 4
Insurance contract or identification number12261558
Number of Individuals Covered18
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $803
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $4,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $773
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number298421
Policy instance 6
Insurance contract or identification number298421
Number of Individuals Covered43
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $2,514
Total amount of fees paid to insurance companyUSD $25
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $15,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,324
Insurance broker organization code?3
Amount paid for insurance broker fees25
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG050V1
Policy instance 5
Insurance contract or identification numberGLUG050V1
Number of Individuals Covered128
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $1,898
Total amount of fees paid to insurance companyUSD $580
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,743
Amount paid for insurance broker fees580
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number9516264
Policy instance 7
Insurance contract or identification number9516264
Number of Individuals Covered37
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $1,908
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT
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 CarrierUSD $7,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,908
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number9516264
Policy instance 1
Insurance contract or identification number9516264
Number of Individuals Covered39
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $2,039
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,039
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number050V1
Policy instance 8
Insurance contract or identification number050V1
Number of Individuals Covered140
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $2,053
Total amount of fees paid to insurance companyUSD $342
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,053
Amount paid for insurance broker fees342
Additional information about fees paid to insurance brokerSALES INCENTIVES
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberH52018
Policy instance 2
Insurance contract or identification numberH52018
Number of Individuals Covered14
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $5,101
Welfare Benefit Premiums Paid to CarrierUSD $112,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,101
Insurance broker organization code?3
Insurance broker nameJ. D. GILMOUR & CO., INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225504
Policy instance 3
Insurance contract or identification number225504
Number of Individuals Covered55
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $9,771
Welfare Benefit Premiums Paid to CarrierUSD $297,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,771
Insurance broker organization code?3
Insurance broker nameJ. D. GILMOUR & CO., INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number298421
Policy instance 4
Insurance contract or identification number298421
Number of Individuals Covered52
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $3,174
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,174
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12261558
Policy instance 5
Insurance contract or identification number12261558
Number of Individuals Covered22
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $427
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $427
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number5458643
Policy instance 6
Insurance contract or identification number5458643
Number of Individuals Covered23
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $548
Total amount of fees paid to insurance companyUSD $27
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $548
Amount paid for insurance broker fees27
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5458643
Policy instance 7
Insurance contract or identification number5458643
Number of Individuals Covered26
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $2,073
Total amount of fees paid to insurance companyUSD $102
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,073
Amount paid for insurance broker fees102
Additional information about fees paid to insurance brokerSALES INCENTIVE
Insurance broker organization code?3
Insurance broker nameJOHN M. GILMOUR, INC.
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberVARIOUS
Policy instance 6
Insurance contract or identification numberVARIOUS
Number of Individuals Covered15
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $5,155
Welfare Benefit Premiums Paid to CarrierUSD $111,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225504
Policy instance 5
Insurance contract or identification number225504
Number of Individuals Covered42
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $10,694
Welfare Benefit Premiums Paid to CarrierUSD $250,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG00050V1
Policy instance 4
Insurance contract or identification numberG00050V1
Number of Individuals Covered134
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $3,807
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5458643
Policy instance 3
Insurance contract or identification number5458643
Number of Individuals Covered24
Insurance policy start date2011-06-01
Insurance policy end date2012-06-01
Total amount of commissions paid to insurance brokerUSD $1,727
Total amount of fees paid to insurance companyUSD $82
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number5458643
Policy instance 2
Insurance contract or identification number5458643
Number of Individuals Covered20
Insurance policy start date2011-06-01
Insurance policy end date2012-06-01
Total amount of commissions paid to insurance brokerUSD $487
Total amount of fees paid to insurance companyUSD $24
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,674
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 numberEWS30
Policy instance 1
Insurance contract or identification numberEWS30
Number of Individuals Covered16
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $2,006
Total amount of fees paid to insurance companyUSD $3
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCANCER INSURANCE, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $3,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12261558
Policy instance 7
Insurance contract or identification number12261558
Number of Individuals Covered15
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $324
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12261558
Policy instance 5
Insurance contract or identification number12261558
Number of Individuals Covered21
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $379
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,793
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 numberVARIOUS
Policy instance 4
Insurance contract or identification numberVARIOUS
Number of Individuals Covered20
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $8,121
Total amount of fees paid to insurance companyUSD $22
Welfare Benefit Premiums Paid to CarrierUSD $175,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG00050V1
Policy instance 2
Insurance contract or identification numberG00050V1
Number of Individuals Covered130
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $3,520
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,009
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 number00438200
Policy instance 1
Insurance contract or identification number00438200
Number of Individuals Covered46
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $3,400
Total amount of fees paid to insurance companyUSD $1,441
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $33,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number225504
Policy instance 3
Insurance contract or identification number225504
Number of Individuals Covered46
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $8,598
Welfare Benefit Premiums Paid to CarrierUSD $271,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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