MAG-TEK, INC. has sponsored the creation of one or more 401k plans.
Additional information about MAG-TEK, INC.
Submission information for form 5500 for 401k plan MAG-TEK, INC.
401k plan membership statisitcs for MAG-TEK, INC.
| Measure | Date | Value |
|---|
| 2022: MAG-TEK, INC. 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-07-01 | 153 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 147 |
| Number of retired or separated participants receiving benefits | 2022-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-07-01 | 0 |
| Total of all active and inactive participants | 2022-07-01 | 147 |
| Number of employers contributing to the scheme | 2022-07-01 | 0 |
| 2021: MAG-TEK, INC. 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-07-01 | 195 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 153 |
| Number of retired or separated participants receiving benefits | 2021-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
| Total of all active and inactive participants | 2021-07-01 | 153 |
| Number of employers contributing to the scheme | 2021-07-01 | 0 |
| 2020: MAG-TEK, INC. 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 226 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 161 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 25 |
| Total of all active and inactive participants | 2020-07-01 | 195 |
| Number of employers contributing to the scheme | 2020-07-01 | 0 |
| 2019: MAG-TEK, INC. 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 234 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 225 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-07-01 | 0 |
| Total of all active and inactive participants | 2019-07-01 | 226 |
| Number of employers contributing to the scheme | 2019-07-01 | 0 |
| 2018: MAG-TEK, INC. 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 241 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 232 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
| Total of all active and inactive participants | 2018-07-01 | 234 |
| Number of employers contributing to the scheme | 2018-07-01 | 0 |
| 2017: MAG-TEK, INC. 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 246 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 238 |
| Number of retired or separated participants receiving benefits | 2017-07-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2017-07-01 | 0 |
| Total of all active and inactive participants | 2017-07-01 | 241 |
| Number of employers contributing to the scheme | 2017-07-01 | 0 |
| 2016: MAG-TEK, INC. 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 243 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 238 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2016-07-01 | 5 |
| Total of all active and inactive participants | 2016-07-01 | 246 |
| 2015: MAG-TEK, INC. 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 244 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 238 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-07-01 | 0 |
| Total of all active and inactive participants | 2015-07-01 | 239 |
| 2014: MAG-TEK, INC. 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 232 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 240 |
| Number of retired or separated participants receiving benefits | 2014-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2014-07-01 | 5 |
| Total of all active and inactive participants | 2014-07-01 | 246 |
| 2013: MAG-TEK, INC. 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 223 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 232 |
| Number of retired or separated participants receiving benefits | 2013-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-07-01 | 0 |
| Total of all active and inactive participants | 2013-07-01 | 232 |
| 2012: MAG-TEK, INC. 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-07-01 | 217 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 220 |
| Number of retired or separated participants receiving benefits | 2012-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-07-01 | 3 |
| Total of all active and inactive participants | 2012-07-01 | 223 |
| 2011: MAG-TEK, INC. 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-07-01 | 211 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 208 |
| Number of retired or separated participants receiving benefits | 2011-07-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2011-07-01 | 0 |
| Total of all active and inactive participants | 2011-07-01 | 217 |
| 2009: MAG-TEK, INC. 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-07-01 | 212 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 211 |
| Number of retired or separated participants receiving benefits | 2009-07-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2009-07-01 | 0 |
| Total of all active and inactive participants | 2009-07-01 | 222 |
| 2022: MAG-TEK, INC. 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: MAG-TEK, INC. 2021 form 5500 responses |
|---|
| 2021-07-01 | Type of plan entity | Single employer plan |
| 2021-07-01 | Plan funding arrangement – Insurance | Yes |
| 2021-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: MAG-TEK, INC. 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: MAG-TEK, INC. 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: MAG-TEK, INC. 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: MAG-TEK, INC. 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: MAG-TEK, INC. 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Submission has been amended | No |
| 2016-07-01 | This submission is the final filing | No |
| 2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-07-01 | Plan is a collectively bargained plan | No |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: MAG-TEK, INC. 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Submission has been amended | No |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: MAG-TEK, INC. 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Submission has been amended | No |
| 2014-07-01 | This submission is the final filing | No |
| 2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-07-01 | Plan is a collectively bargained plan | No |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: MAG-TEK, INC. 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: MAG-TEK, INC. 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Submission has been amended | No |
| 2012-07-01 | This submission is the final filing | No |
| 2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-07-01 | Plan is a collectively bargained plan | No |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: MAG-TEK, INC. 2011 form 5500 responses |
|---|
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | Submission has been amended | No |
| 2011-07-01 | This submission is the final filing | No |
| 2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-07-01 | Plan is a collectively bargained plan | No |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: MAG-TEK, INC. 2009 form 5500 responses |
|---|
| 2009-07-01 | Type of plan entity | Single employer plan |
| 2009-07-01 | Submission has been amended | No |
| 2009-07-01 | This submission is the final filing | No |
| 2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-07-01 | Plan is a collectively bargained plan | No |
| 2009-07-01 | Plan funding arrangement – Insurance | Yes |
| 2009-07-01 | Plan benefit arrangement – Insurance | Yes |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 121578 |
| Policy instance | 2 |
| Insurance contract or identification number | 121578 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $7,194 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $152,726 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,194 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C19327 |
| Policy instance | 1 |
| Insurance contract or identification number | C19327 | | Number of Individuals Covered | 446 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $127,660 | | Total amount of fees paid to insurance company | USD $11,631 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision 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 | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $2,321,033 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $127,660 | | Amount paid for insurance broker fees | 6911 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 121578 |
| Policy instance | 2 |
| Insurance contract or identification number | 121578 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $5,982 | | Total amount of fees paid to insurance company | USD $23 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $155,949 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,982 | | Amount paid for insurance broker fees | 23 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C19327 |
| Policy instance | 1 |
| Insurance contract or identification number | C19327 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $140,729 | | Total amount of fees paid to insurance company | USD $11,090 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision 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 | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $2,536,909 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $140,729 | | Amount paid for insurance broker fees | 6506 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10008551001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10008551001 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $2,315 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,691 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,315 | | 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 | 121578 |
| Policy instance | 3 |
| Insurance contract or identification number | 121578 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $8,283 | | Total amount of fees paid to insurance company | USD $263 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $153,395 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,283 | | Amount paid for insurance broker fees | 263 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK960435 |
| Policy instance | 4 |
| Insurance contract or identification number | LK960435 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $7,698 | | Total amount of fees paid to insurance company | USD $1,563 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $75,753 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,698 | | Amount paid for insurance broker fees | 1563 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C19327 |
| Policy instance | 1 |
| Insurance contract or identification number | C19327 | | Number of Individuals Covered | 375 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $156,610 | | Total amount of fees paid to insurance company | USD $5,607 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,863,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $156,610 | | Amount paid for insurance broker fees | 1534 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK960435 |
| Policy instance | 4 |
| Insurance contract or identification number | LK960435 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $8,528 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $83,342 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,528 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 100085510001 |
| Policy instance | 2 |
| Insurance contract or identification number | 100085510001 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $2,640 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,365 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,640 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C19327 |
| Policy instance | 1 |
| Insurance contract or identification number | C19327 | | Number of Individuals Covered | 449 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $168,796 | | Total amount of fees paid to insurance company | USD $1,227 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,294,816 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $168,796 | | Amount paid for insurance broker fees | 467 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 121578 |
| Policy instance | 3 |
| Insurance contract or identification number | 121578 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $8,182 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $150,839 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,182 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 100085510001 |
| Policy instance | 2 |
| Insurance contract or identification number | 100085510001 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $2,594 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,045 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,594 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C19327 |
| Policy instance | 1 |
| Insurance contract or identification number | C19327 | | Number of Individuals Covered | 442 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $145,317 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,739,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $134,498 | | 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 | 121578 |
| Policy instance | 3 |
| Insurance contract or identification number | 121578 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $8,948 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $165,670 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,948 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK960435 |
| Policy instance | 4 |
| Insurance contract or identification number | LK960435 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $7,954 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $77,846 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,954 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 919943-099 |
| Policy instance | 5 |
| Insurance contract or identification number | 919943-099 | | Number of Individuals Covered | 360 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $6,918 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $163,625 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C19327 |
| Policy instance | 1 |
| Insurance contract or identification number | C19327 | | Number of Individuals Covered | 352 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $132,082 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,628,364 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
| Policy contract number | 919943-001 |
| Policy instance | 2 |
| Insurance contract or identification number | 919943-001 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,088 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,923 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10008551001 |
| Policy instance | 3 |
| Insurance contract or identification number | 10008551001 | | Number of Individuals Covered | 289 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $2,430 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,505 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK960435 |
| Policy instance | 6 |
| Insurance contract or identification number | LK960435 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $8,067 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $79,143 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 121578 |
| Policy instance | 4 |
| Insurance contract or identification number | 121578 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $8,156 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $151,764 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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