CAMPO BAND OF MISSION INDIANS has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN
401k plan membership statisitcs for GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN
Measure | Date | Value |
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2022: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-06-01 | 238 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-06-01 | 203 |
Number of retired or separated participants receiving benefits | 2022-06-01 | 3 |
Number of other retired or separated participants entitled to future benefits | 2022-06-01 | 0 |
Total of all active and inactive participants | 2022-06-01 | 206 |
2021: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-06-01 | 168 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-06-01 | 238 |
Number of retired or separated participants receiving benefits | 2021-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-06-01 | 0 |
Total of all active and inactive participants | 2021-06-01 | 238 |
2020: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-06-01 | 195 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-06-01 | 163 |
Number of retired or separated participants receiving benefits | 2020-06-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2020-06-01 | 0 |
Total of all active and inactive participants | 2020-06-01 | 168 |
2019: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-06-01 | 217 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-06-01 | 195 |
Number of retired or separated participants receiving benefits | 2019-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2019-06-01 | 0 |
Total of all active and inactive participants | 2019-06-01 | 195 |
2018: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-06-01 | 225 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-06-01 | 217 |
Number of retired or separated participants receiving benefits | 2018-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2018-06-01 | 0 |
Total of all active and inactive participants | 2018-06-01 | 217 |
2017: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-06-01 | 271 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 225 |
Number of retired or separated participants receiving benefits | 2017-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2017-06-01 | 0 |
Total of all active and inactive participants | 2017-06-01 | 225 |
2016: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-06-01 | 283 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 270 |
Number of retired or separated participants receiving benefits | 2016-06-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2016-06-01 | 0 |
Total of all active and inactive participants | 2016-06-01 | 271 |
2015: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-06-01 | 272 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 281 |
Number of retired or separated participants receiving benefits | 2015-06-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 0 |
Total of all active and inactive participants | 2015-06-01 | 283 |
2014: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-06-01 | 247 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-06-01 | 271 |
Number of retired or separated participants receiving benefits | 2014-06-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2014-06-01 | 0 |
Total of all active and inactive participants | 2014-06-01 | 272 |
2013: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-06-01 | 236 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 247 |
Number of retired or separated participants receiving benefits | 2013-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 0 |
Total of all active and inactive participants | 2013-06-01 | 247 |
2012: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-06-01 | 236 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 235 |
Number of retired or separated participants receiving benefits | 2012-06-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2012-06-01 | 0 |
Total of all active and inactive participants | 2012-06-01 | 236 |
2011: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-06-01 | 239 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-06-01 | 235 |
Number of retired or separated participants receiving benefits | 2011-06-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2011-06-01 | 0 |
Total of all active and inactive participants | 2011-06-01 | 236 |
2010: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2010 401k membership |
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Total participants, beginning-of-year | 2010-06-01 | 586 |
Total number of active participants reported on line 7a of the Form 5500 | 2010-06-01 | 510 |
Number of retired or separated participants receiving benefits | 2010-06-01 | 4 |
Number of other retired or separated participants entitled to future benefits | 2010-06-01 | 0 |
Total of all active and inactive participants | 2010-06-01 | 514 |
2009: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-06-01 | 580 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-06-01 | 586 |
Number of retired or separated participants receiving benefits | 2009-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2009-06-01 | 0 |
Total of all active and inactive participants | 2009-06-01 | 586 |
2022: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2022 form 5500 responses |
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2022-06-01 | Type of plan entity | Single employer plan |
2022-06-01 | Submission has been amended | No |
2022-06-01 | This submission is the final filing | No |
2022-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2022-06-01 | Plan is a collectively bargained plan | No |
2022-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-06-01 | Plan benefit arrangement – Insurance | Yes |
2021: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2021 form 5500 responses |
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2021-06-01 | Type of plan entity | Single employer plan |
2021-06-01 | Submission has been amended | No |
2021-06-01 | This submission is the final filing | No |
2021-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-06-01 | Plan is a collectively bargained plan | No |
2021-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-06-01 | Plan benefit arrangement – Insurance | Yes |
2020: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2020 form 5500 responses |
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2020-06-01 | Type of plan entity | Single employer plan |
2020-06-01 | Submission has been amended | No |
2020-06-01 | This submission is the final filing | No |
2020-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-06-01 | Plan is a collectively bargained plan | No |
2020-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-06-01 | Plan benefit arrangement – Insurance | Yes |
2019: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2019 form 5500 responses |
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2019-06-01 | Type of plan entity | Single employer plan |
2019-06-01 | Submission has been amended | No |
2019-06-01 | This submission is the final filing | No |
2019-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-06-01 | Plan is a collectively bargained plan | No |
2019-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-06-01 | Plan benefit arrangement – Insurance | Yes |
2018: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2018 form 5500 responses |
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2018-06-01 | Type of plan entity | Single employer plan |
2018-06-01 | Submission has been amended | No |
2018-06-01 | This submission is the final filing | No |
2018-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-06-01 | Plan is a collectively bargained plan | No |
2018-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-06-01 | Plan benefit arrangement – Insurance | Yes |
2017: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2017 form 5500 responses |
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2017-06-01 | Type of plan entity | Single employer plan |
2017-06-01 | Submission has been amended | No |
2017-06-01 | This submission is the final filing | No |
2017-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-06-01 | Plan is a collectively bargained plan | No |
2017-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-06-01 | Plan benefit arrangement – Insurance | Yes |
2016: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2016 form 5500 responses |
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2016-06-01 | Type of plan entity | Single employer plan |
2016-06-01 | Submission has been amended | No |
2016-06-01 | This submission is the final filing | No |
2016-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-06-01 | Plan is a collectively bargained plan | No |
2016-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2016-06-01 | Plan benefit arrangement – Insurance | Yes |
2015: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2015 form 5500 responses |
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2015-06-01 | Type of plan entity | Single employer plan |
2015-06-01 | Submission has been amended | No |
2015-06-01 | This submission is the final filing | No |
2015-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-06-01 | Plan is a collectively bargained plan | No |
2015-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2015-06-01 | Plan benefit arrangement – Insurance | Yes |
2014: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2014 form 5500 responses |
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2014-06-01 | Type of plan entity | Single employer plan |
2014-06-01 | Submission has been amended | No |
2014-06-01 | This submission is the final filing | No |
2014-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-06-01 | Plan is a collectively bargained plan | No |
2014-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2014-06-01 | Plan benefit arrangement – Insurance | Yes |
2013: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2013 form 5500 responses |
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2013-06-01 | Type of plan entity | Single employer plan |
2013-06-01 | Submission has been amended | No |
2013-06-01 | This submission is the final filing | No |
2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-06-01 | Plan is a collectively bargained plan | No |
2013-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2013-06-01 | Plan benefit arrangement – Insurance | Yes |
2012: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2012 form 5500 responses |
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2012-06-01 | Type of plan entity | Single employer plan |
2012-06-01 | Submission has been amended | No |
2012-06-01 | This submission is the final filing | No |
2012-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-06-01 | Plan is a collectively bargained plan | No |
2012-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2012-06-01 | Plan benefit arrangement – Insurance | Yes |
2011: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2011 form 5500 responses |
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2011-06-01 | Type of plan entity | Single employer plan |
2011-06-01 | Submission has been amended | No |
2011-06-01 | This submission is the final filing | No |
2011-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-06-01 | Plan is a collectively bargained plan | No |
2011-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2011-06-01 | Plan benefit arrangement – Insurance | Yes |
2010: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2010 form 5500 responses |
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2010-06-01 | Type of plan entity | Single employer plan |
2010-06-01 | Submission has been amended | No |
2010-06-01 | This submission is the final filing | No |
2010-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2010-06-01 | Plan is a collectively bargained plan | No |
2010-06-01 | Plan funding arrangement – Insurance | Yes |
2010-06-01 | Plan benefit arrangement – Insurance | Yes |
2009: GOLDEN ACORN CASINO & TRAVEL CENTER WELFARE BENEFITS PLAN 2009 form 5500 responses |
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2009-06-01 | Type of plan entity | Single employer plan |
2009-06-01 | Submission has been amended | No |
2009-06-01 | This submission is the final filing | No |
2009-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2009-06-01 | Plan is a collectively bargained plan | No |
2009-06-01 | Plan funding arrangement – Insurance | Yes |
2009-06-01 | Plan benefit arrangement – Insurance | Yes |
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 221213 |
Policy instance | 2 |
Insurance contract or identification number | 221213 | Number of Individuals Covered | 187 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $5,051 | Total amount of fees paid to insurance company | USD $462 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $38,175 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,398 | Amount paid for insurance broker fees | 313 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
|
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5917210 |
Policy instance | 6 |
Insurance contract or identification number | 5917210 | Number of Individuals Covered | 219 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $4,179 | Total amount of fees paid to insurance company | USD $500 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $60,595 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,179 | Amount paid for insurance broker fees | 500 | Additional information about fees paid to insurance broker | NON-MONETARY AND SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
Policy contract number | 0547600000 |
Policy instance | 5 |
Insurance contract or identification number | 0547600000 | Number of Individuals Covered | 46 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $4,058 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $21,412 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,566 | Insurance broker organization code? | 3 |
|
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 200466 |
Policy instance | 4 |
Insurance contract or identification number | 200466 | Number of Individuals Covered | 61 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $7,212 | Total amount of fees paid to insurance company | USD $604 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $57,859 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,063 | Amount paid for insurance broker fees | 416 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180/9180 |
Policy instance | 3 |
Insurance contract or identification number | 180/9180 | Number of Individuals Covered | 104 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $9,131 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $228,281 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,131 | Insurance broker organization code? | 3 |
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SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 ) |
Policy contract number | 1002825 |
Policy instance | 1 |
Insurance contract or identification number | 1002825 | Number of Individuals Covered | 155 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $29,012 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $580,239 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $29,012 | Insurance broker organization code? | 3 |
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SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
Policy contract number | 5917210 |
Policy instance | 7 |
Insurance contract or identification number | 5917210 | Number of Individuals Covered | 54 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $1,275 | Total amount of fees paid to insurance company | USD $124 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $15,344 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,275 | Amount paid for insurance broker fees | 124 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
|
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180/9180 |
Policy instance | 3 |
Insurance contract or identification number | 180/9180 | Number of Individuals Covered | 89 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $7,833 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $196,503 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,833 | Insurance broker organization code? | 3 |
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SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
Policy contract number | 5917210 |
Policy instance | 2 |
Insurance contract or identification number | 5917210 | Number of Individuals Covered | 70 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $1,389 | Total amount of fees paid to insurance company | USD $145 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $12,655 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,389 | Amount paid for insurance broker fees | 145 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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MEDIEXCEL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15347 ) |
Policy contract number | E113 |
Policy instance | 1 |
Insurance contract or identification number | E113 | Number of Individuals Covered | 108 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $2,196 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $51,227 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,196 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 200466 |
Policy instance | 4 |
Insurance contract or identification number | 200466 | Number of Individuals Covered | 356 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $8,988 | Total amount of fees paid to insurance company | USD $715 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $46,587 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,222 | Amount paid for insurance broker fees | 538 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 221213 |
Policy instance | 5 |
Insurance contract or identification number | 221213 | Number of Individuals Covered | 166 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $6,341 | Total amount of fees paid to insurance company | USD $568 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $36,100 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,271 | Amount paid for insurance broker fees | 420 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5917210 |
Policy instance | 6 |
Insurance contract or identification number | 5917210 | Number of Individuals Covered | 187 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $3,453 | Total amount of fees paid to insurance company | USD $462 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $34,499 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,453 | Amount paid for insurance broker fees | 462 | Additional information about fees paid to insurance broker | NON-MONETARY AND SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 ) |
Policy contract number | 1002825 |
Policy instance | 7 |
Insurance contract or identification number | 1002825 | Number of Individuals Covered | 121 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $29,887 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $597,741 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $29,887 | Insurance broker organization code? | 3 |
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TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
Policy contract number | 0547600000 |
Policy instance | 8 |
Insurance contract or identification number | 0547600000 | Number of Individuals Covered | 32 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $6,046 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $11,521 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,388 | Insurance broker organization code? | 3 |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180 |
Policy instance | 1 |
Insurance contract or identification number | 180 | Number of Individuals Covered | 100 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $9,594 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $248,514 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,594 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5917210 |
Policy instance | 2 |
Insurance contract or identification number | 5917210 | Number of Individuals Covered | 199 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $3,400 | Total amount of fees paid to insurance company | USD $602 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $38,328 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,400 | Amount paid for insurance broker fees | 602 | Additional information about fees paid to insurance broker | NON-MONETARY AND SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
Policy contract number | 5917210 |
Policy instance | 3 |
Insurance contract or identification number | 5917210 | Number of Individuals Covered | 61 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $1,289 | Total amount of fees paid to insurance company | USD $175 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $13,170 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,289 | Amount paid for insurance broker fees | 175 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 200466 |
Policy instance | 4 |
Insurance contract or identification number | 200466 | Number of Individuals Covered | 319 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $7,665 | Total amount of fees paid to insurance company | USD $229 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $43,926 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,973 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 229 | Additional information about fees paid to insurance broker | NON-MONETARY AND SUPPLEMENTAL COMPENSATION |
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CALIFORNIACHOICE (National Association of Insurance Commissioners NAIC id number: ) |
Policy contract number | 18064 |
Policy instance | 5 |
Insurance contract or identification number | 18064 | Number of Individuals Covered | 57 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $22,006 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $438,810 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $22,006 | Insurance broker organization code? | 3 |
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SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
Policy contract number | 5917210 |
Policy instance | 5 |
Insurance contract or identification number | 5917210 | Number of Individuals Covered | 51 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $1,548 | Total amount of fees paid to insurance company | USD $178 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $15,426 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,548 | Amount paid for insurance broker fees | 178 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180 |
Policy instance | 4 |
Insurance contract or identification number | 180 | Number of Individuals Covered | 98 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $13,639 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $340,981 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,639 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 200466 |
Policy instance | 3 |
Insurance contract or identification number | 200466 | Number of Individuals Covered | 444 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $20,756 | Total amount of fees paid to insurance company | USD $1,335 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $75,321 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $16,388 | Amount paid for insurance broker fees | 984 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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CALIFORNIACHOICE (National Association of Insurance Commissioners NAIC id number: ) |
Policy contract number | 18064 |
Policy instance | 2 |
Insurance contract or identification number | 18064 | Number of Individuals Covered | 54 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $28,447 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $573,410 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $28,447 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5917210 |
Policy instance | 1 |
Insurance contract or identification number | 5917210 | Number of Individuals Covered | 199 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $4,654 | Total amount of fees paid to insurance company | USD $728 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $56,303 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,654 | Amount paid for insurance broker fees | 728 | Additional information about fees paid to insurance broker | NON-MONETARY AND SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5917210 |
Policy instance | 1 |
Insurance contract or identification number | 5917210 | Number of Individuals Covered | 300 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $4,341 | Total amount of fees paid to insurance company | USD $952 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $49,897 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,341 | Amount paid for insurance broker fees | 952 | Additional information about fees paid to insurance broker | NON-MONETARY AND SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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CALIFORNIACHOICE (National Association of Insurance Commissioners NAIC id number: ) |
Policy contract number | 18039/18064 |
Policy instance | 5 |
Insurance contract or identification number | 18039/18064 | Number of Individuals Covered | 103 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $43,464 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $866,348 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $43,464 | Insurance broker organization code? | 3 |
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SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
Policy contract number | 5917210 |
Policy instance | 2 |
Insurance contract or identification number | 5917210 | Number of Individuals Covered | 55 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $1,310 | Total amount of fees paid to insurance company | USD $210 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $12,190 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,310 | Amount paid for insurance broker fees | 210 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 200466 |
Policy instance | 3 |
Insurance contract or identification number | 200466 | Number of Individuals Covered | 65 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $2,069 | Total amount of fees paid to insurance company | USD $55 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $8,147 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,069 | Amount paid for insurance broker fees | 55 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180/9180 |
Policy instance | 4 |
Insurance contract or identification number | 180/9180 | Number of Individuals Covered | 143 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $15,112 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $379,082 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $15,112 | Insurance broker organization code? | 3 |
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CALIFORNIACHOICE (National Association of Insurance Commissioners NAIC id number: ) |
Policy contract number | 18039/18064 |
Policy instance | 1 |
Insurance contract or identification number | 18039/18064 | Number of Individuals Covered | 108 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $51,189 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $932,674 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180 |
Policy instance | 2 |
Insurance contract or identification number | 180 | Number of Individuals Covered | 201 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $17,797 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $444,924 | 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 | KM05917210 |
Policy instance | 4 |
Insurance contract or identification number | KM05917210 | Number of Individuals Covered | 297 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $4,945 | Total amount of fees paid to insurance company | USD $1,308 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $55,299 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
Policy contract number | KM05917210 |
Policy instance | 3 |
Insurance contract or identification number | KM05917210 | Number of Individuals Covered | 48 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $1,952 | Total amount of fees paid to insurance company | USD $349 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $16,673 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
Policy contract number | KM05917210 |
Policy instance | 1 |
Insurance contract or identification number | KM05917210 | Number of Individuals Covered | 120 | Insurance policy start date | 2015-06-01 | Insurance policy end date | 2016-05-31 | Total amount of commissions paid to insurance broker | USD $2,507 | Total amount of fees paid to insurance company | USD $330 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $24,470 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,507 | Amount paid for insurance broker fees | 330 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL INS SVCS INC. |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05917210 |
Policy instance | 2 |
Insurance contract or identification number | KM05917210 | Number of Individuals Covered | 311 | Insurance policy start date | 2015-06-01 | Insurance policy end date | 2016-05-31 | Total amount of commissions paid to insurance broker | USD $5,042 | Total amount of fees paid to insurance company | USD $781 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $62,990 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,042 | Amount paid for insurance broker fees | 781 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL INS SVCS INC. |
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CALIFORNIACHOICE (National Association of Insurance Commissioners NAIC id number: ) |
Policy contract number | 18064 |
Policy instance | 4 |
Insurance contract or identification number | 18064 | Number of Individuals Covered | 85 | Insurance policy start date | 2015-06-01 | Insurance policy end date | 2016-05-31 | Total amount of commissions paid to insurance broker | USD $37,077 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $574,658 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $37,077 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL INS SVCS INC. |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180 |
Policy instance | 3 |
Insurance contract or identification number | 180 | Number of Individuals Covered | 207 | Insurance policy start date | 2015-06-01 | Insurance policy end date | 2016-05-31 | Total amount of commissions paid to insurance broker | USD $17,074 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $426,857 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,074 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL INS SVCS INC. |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05917210 |
Policy instance | 2 |
Insurance contract or identification number | KM05917210 | Number of Individuals Covered | 337 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $5,683 | Total amount of fees paid to insurance company | USD $3,397 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $52,365 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,683 | Amount paid for insurance broker fees | 3397 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL INS SVCS INC. |
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SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
Policy contract number | KM05917210 |
Policy instance | 1 |
Insurance contract or identification number | KM05917210 | Number of Individuals Covered | 158 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $3,747 | Total amount of fees paid to insurance company | USD $1,989 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $30,084 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,747 | Amount paid for insurance broker fees | 1989 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL INS SVCS INC. |
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CALIFORNIACHOICE (National Association of Insurance Commissioners NAIC id number: ) |
Policy contract number | 18064 |
Policy instance | 3 |
Insurance contract or identification number | 18064 | Number of Individuals Covered | 85 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $37,924 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $581,125 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $37,924 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL INS SVCS INC. |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180 |
Policy instance | 4 |
Insurance contract or identification number | 180 | Number of Individuals Covered | 201 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $16,474 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $411,840 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $16,474 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL INS SVCS INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG 097J1 |
Policy instance | 4 |
Insurance contract or identification number | GLUG 097J1 | Number of Individuals Covered | 247 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $2,249 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $22,486 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,249 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180 |
Policy instance | 1 |
Insurance contract or identification number | 180 | Number of Individuals Covered | 204 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $14,215 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $355,365 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,215 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL |
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DENTAL HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 41067 ) |
Policy contract number | 3445H/3445P |
Policy instance | 2 |
Insurance contract or identification number | 3445H/3445P | Number of Individuals Covered | 84 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $4,293 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $45,763 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,293 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL |
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CALIFORNIACHOICE (National Association of Insurance Commissioners NAIC id number: ) |
Policy contract number | 18064 |
Policy instance | 3 |
Insurance contract or identification number | 18064 | Number of Individuals Covered | 76 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $46,346 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $656,210 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $46,346 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180 |
Policy instance | 1 |
Insurance contract or identification number | 180 | Number of Individuals Covered | 187 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $14,937 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $373,416 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,937 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG 097J1 |
Policy instance | 2 |
Insurance contract or identification number | GLUG 097J1 | Number of Individuals Covered | 235 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $2,299 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $22,996 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,299 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL |
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CALIFORNIACHOICE (National Association of Insurance Commissioners NAIC id number: ) |
Policy contract number | 18064 |
Policy instance | 3 |
Insurance contract or identification number | 18064 | Number of Individuals Covered | 78 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $44,687 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $635,556 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $44,687 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL |
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DENTAL HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 41067 ) |
Policy contract number | 3445H/3445P |
Policy instance | 4 |
Insurance contract or identification number | 3445H/3445P | Number of Individuals Covered | 73 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $3,283 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $34,799 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,283 | Insurance broker organization code? | 3 | Insurance broker name | HUB INTERNATIONAL |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG 097J1 |
Policy instance | 3 |
Insurance contract or identification number | GLUG 097J1 | Number of Individuals Covered | 235 | Insurance policy start date | 2011-06-01 | Insurance policy end date | 2012-05-31 | Total amount of commissions paid to insurance broker | USD $2,364 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $23,645 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DENTAL HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 41067 ) |
Policy contract number | 3445H/3445P |
Policy instance | 4 |
Insurance contract or identification number | 3445H/3445P | Number of Individuals Covered | 72 | Insurance policy start date | 2011-06-01 | Insurance policy end date | 2012-05-31 | Total amount of commissions paid to insurance broker | USD $3,304 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $35,800 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CALIFORNIACHOICE (National Association of Insurance Commissioners NAIC id number: ) |
Policy contract number | 18064 |
Policy instance | 2 |
Insurance contract or identification number | 18064 | Number of Individuals Covered | 84 | Insurance policy start date | 2011-06-01 | Insurance policy end date | 2012-05-31 | Total amount of commissions paid to insurance broker | USD $44,286 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $632,276 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180 |
Policy instance | 1 |
Insurance contract or identification number | 180 | Number of Individuals Covered | 201 | Insurance policy start date | 2011-06-01 | Insurance policy end date | 2012-05-31 | Total amount of commissions paid to insurance broker | USD $12,641 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $316,030 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CALIFORNIACHOICE (National Association of Insurance Commissioners NAIC id number: ) |
Policy contract number | 18064 |
Policy instance | 4 |
Insurance contract or identification number | 18064 | Number of Individuals Covered | 88 | Insurance policy start date | 2010-06-01 | Insurance policy end date | 2011-05-31 | Total amount of commissions paid to insurance broker | USD $39,943 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $568,662 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 180 |
Policy instance | 3 |
Insurance contract or identification number | 180 | Number of Individuals Covered | 192 | Insurance policy start date | 2010-06-01 | Insurance policy end date | 2011-05-31 | Total amount of commissions paid to insurance broker | USD $11,659 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $291,474 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DENTAL HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 41067 ) |
Policy contract number | 3445H/3445P |
Policy instance | 2 |
Insurance contract or identification number | 3445H/3445P | Number of Individuals Covered | 85 | Insurance policy start date | 2010-06-01 | Insurance policy end date | 2011-05-31 | Total amount of commissions paid to insurance broker | USD $3,286 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $35,542 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG 097J1 |
Policy instance | 1 |
Insurance contract or identification number | GLUG 097J1 | Number of Individuals Covered | 510 | Insurance policy start date | 2010-06-01 | Insurance policy end date | 2011-05-31 | Total amount of commissions paid to insurance broker | USD $2,763 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $27,627 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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