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GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan NameGOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN
Plan identification number 501

GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

GOLDEN STATE DRILLING, INC. has sponsored the creation of one or more 401k plans.

Company Name:GOLDEN STATE DRILLING, INC.
Employer identification number (EIN):953152814
NAIC Classification:211120
NAIC Description:Crude Petroleum Extraction

Additional information about GOLDEN STATE DRILLING, INC.

Jurisdiction of Incorporation: California Department of State
Incorporation Date: 1977-02-11
Company Identification Number: C0809136
Legal Registered Office Address: 3500 Fruitvale Ave

Bakersfield
United States of America (USA)
93308

More information about GOLDEN STATE DRILLING, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012020-03-01MELANIE DAY2021-08-19
5012019-03-01MELANIE DAY2020-09-15
5012018-03-01
5012018-03-01
5012017-03-01MELANIE DAY
5012016-03-01MELANIE DAY
5012015-03-01MELANIE DAY
5012014-03-01MELANIE DAY
5012013-03-01MELANIE DAY
5012012-03-01MELANIE DAY MELANIE DAY2013-09-09
5012011-03-01MELANIE DAY
5012009-03-01MELANIE DAY
5012008-03-01 MELANIE DAY2010-06-09
5012007-03-01 MELANIE DAY2010-06-09
5012006-03-01 MELANIE DAY2010-06-09
5012005-03-01 MELANIE DAY2010-06-09
5012004-03-01 MELANIE DAY2010-06-09
5012003-03-01 MELANIE DAY2010-06-09
5012002-03-01 MELANIE DAY2010-06-09
5012001-03-01 MELANIE DAY2010-06-09
5012000-03-01 MELANIE DAY2010-06-09

Plan Statistics for GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2020: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-03-01275
Total number of active participants reported on line 7a of the Form 55002020-03-0185
Number of retired or separated participants receiving benefits2020-03-015
Number of other retired or separated participants entitled to future benefits2020-03-010
Total of all active and inactive participants2020-03-0190
Number of employers contributing to the scheme2020-03-010
2019: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-03-01275
Total number of active participants reported on line 7a of the Form 55002019-03-01275
Number of retired or separated participants receiving benefits2019-03-010
Number of other retired or separated participants entitled to future benefits2019-03-010
Total of all active and inactive participants2019-03-01275
Number of employers contributing to the scheme2019-03-010
2018: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-03-01250
Total number of active participants reported on line 7a of the Form 55002018-03-01275
Number of other retired or separated participants entitled to future benefits2018-03-010
Total of all active and inactive participants2018-03-01275
Total participants2018-03-01275
2017: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-03-01173
Total number of active participants reported on line 7a of the Form 55002017-03-01250
Total of all active and inactive participants2017-03-01250
Total participants2017-03-01250
2016: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-03-01335
Total number of active participants reported on line 7a of the Form 55002016-03-01173
Total of all active and inactive participants2016-03-01173
Total participants2016-03-01173
2015: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-03-01316
Total number of active participants reported on line 7a of the Form 55002015-03-01335
Total of all active and inactive participants2015-03-01335
Total participants2015-03-01335
2014: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-03-01345
Total number of active participants reported on line 7a of the Form 55002014-03-01316
Total of all active and inactive participants2014-03-01316
Total participants2014-03-01316
2013: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-03-01325
Total number of active participants reported on line 7a of the Form 55002013-03-01345
Total of all active and inactive participants2013-03-01345
Total participants2013-03-01345
2012: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-03-01321
Total number of active participants reported on line 7a of the Form 55002012-03-01325
Total of all active and inactive participants2012-03-01325
Total participants2012-03-01325
2011: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-03-01321
Total number of active participants reported on line 7a of the Form 55002011-03-01321
Total of all active and inactive participants2011-03-01321
Total participants2011-03-01321
2009: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-03-01210
Total number of active participants reported on line 7a of the Form 55002009-03-01321
Total of all active and inactive participants2009-03-01321
Total participants2009-03-01321
2008: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year2008-03-01210
2007: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2007 401k membership
Total participants, beginning-of-year2007-03-01210
Total number of active participants reported on line 7a of the Form 55002007-03-01272
Total of all active and inactive participants2007-03-01272
Total participants2007-03-01272
2006: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2006 401k membership
Total participants, beginning-of-year2006-03-01210
Total number of active participants reported on line 7a of the Form 55002006-03-01210
Total of all active and inactive participants2006-03-01210
Total participants2006-03-01210
2005: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2005 401k membership
Total participants, beginning-of-year2005-03-01182
Total number of active participants reported on line 7a of the Form 55002005-03-01210
Total of all active and inactive participants2005-03-01210
Total participants2005-03-01210
2004: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2004 401k membership
Total participants, beginning-of-year2004-03-01186
Total number of active participants reported on line 7a of the Form 55002004-03-01182
Total of all active and inactive participants2004-03-01182
Total participants2004-03-01182
2003: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2003 401k membership
Total participants, beginning-of-year2003-03-01176
Total number of active participants reported on line 7a of the Form 55002003-03-01186
Total of all active and inactive participants2003-03-01186
Total participants2003-03-01186
2002: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2002 401k membership
Total participants, beginning-of-year2002-03-01162
Total number of active participants reported on line 7a of the Form 55002002-03-01176
Total of all active and inactive participants2002-03-01176
Total participants2002-03-01176
2001: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2001 401k membership
Total participants, beginning-of-year2001-03-01161
Total number of active participants reported on line 7a of the Form 55002001-03-01162
Total of all active and inactive participants2001-03-01162
Total participants2001-03-01162
2000: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2000 401k membership
Total participants, beginning-of-year2000-03-0198
Total number of active participants reported on line 7a of the Form 55002000-03-01161
Total of all active and inactive participants2000-03-01161
Total participants2000-03-01161

Form 5500 Responses for GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN

2020: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-03-01Type of plan entitySingle employer plan
2020-03-01Plan funding arrangement – InsuranceYes
2020-03-01Plan benefit arrangement – InsuranceYes
2019: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-03-01Type of plan entitySingle employer plan
2019-03-01Plan funding arrangement – InsuranceYes
2019-03-01Plan benefit arrangement – InsuranceYes
2018: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-03-01Type of plan entitySingle employer plan
2018-03-01Submission has been amendedNo
2018-03-01This submission is the final filingNo
2018-03-01This return/report is a short plan year return/report (less than 12 months)No
2018-03-01Plan is a collectively bargained planNo
2018-03-01Plan funding arrangement – InsuranceYes
2018-03-01Plan funding arrangement – General assets of the sponsorYes
2018-03-01Plan benefit arrangement – General assets of the sponsorYes
2017: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-03-01Type of plan entitySingle employer plan
2017-03-01Submission has been amendedNo
2017-03-01This submission is the final filingNo
2017-03-01This return/report is a short plan year return/report (less than 12 months)No
2017-03-01Plan is a collectively bargained planNo
2017-03-01Plan funding arrangement – InsuranceYes
2017-03-01Plan funding arrangement – General assets of the sponsorYes
2017-03-01Plan benefit arrangement – General assets of the sponsorYes
2016: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-03-01Type of plan entitySingle employer plan
2016-03-01Submission has been amendedNo
2016-03-01This submission is the final filingNo
2016-03-01This return/report is a short plan year return/report (less than 12 months)No
2016-03-01Plan is a collectively bargained planNo
2016-03-01Plan funding arrangement – InsuranceYes
2016-03-01Plan funding arrangement – General assets of the sponsorYes
2016-03-01Plan benefit arrangement – InsuranceYes
2016-03-01Plan benefit arrangement – General assets of the sponsorYes
2015: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-03-01Type of plan entitySingle employer plan
2015-03-01Submission has been amendedNo
2015-03-01This submission is the final filingNo
2015-03-01This return/report is a short plan year return/report (less than 12 months)No
2015-03-01Plan is a collectively bargained planNo
2015-03-01Plan funding arrangement – InsuranceYes
2015-03-01Plan funding arrangement – General assets of the sponsorYes
2015-03-01Plan benefit arrangement – InsuranceYes
2015-03-01Plan benefit arrangement – General assets of the sponsorYes
2014: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-03-01Type of plan entitySingle employer plan
2014-03-01Submission has been amendedNo
2014-03-01This submission is the final filingNo
2014-03-01This return/report is a short plan year return/report (less than 12 months)No
2014-03-01Plan is a collectively bargained planNo
2014-03-01Plan funding arrangement – InsuranceYes
2014-03-01Plan funding arrangement – General assets of the sponsorYes
2014-03-01Plan benefit arrangement – InsuranceYes
2014-03-01Plan benefit arrangement – General assets of the sponsorYes
2013: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-03-01Type of plan entitySingle employer plan
2013-03-01Submission has been amendedNo
2013-03-01This submission is the final filingNo
2013-03-01This return/report is a short plan year return/report (less than 12 months)No
2013-03-01Plan is a collectively bargained planNo
2013-03-01Plan funding arrangement – InsuranceYes
2013-03-01Plan funding arrangement – General assets of the sponsorYes
2013-03-01Plan benefit arrangement – InsuranceYes
2013-03-01Plan benefit arrangement – General assets of the sponsorYes
2012: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-03-01Type of plan entitySingle employer plan
2012-03-01Submission has been amendedNo
2012-03-01This submission is the final filingNo
2012-03-01This return/report is a short plan year return/report (less than 12 months)No
2012-03-01Plan is a collectively bargained planNo
2012-03-01Plan funding arrangement – InsuranceYes
2012-03-01Plan funding arrangement – General assets of the sponsorYes
2012-03-01Plan benefit arrangement – InsuranceYes
2012-03-01Plan benefit arrangement – General assets of the sponsorYes
2011: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-03-01Type of plan entitySingle employer plan
2011-03-01Submission has been amendedYes
2011-03-01This submission is the final filingNo
2011-03-01This return/report is a short plan year return/report (less than 12 months)No
2011-03-01Plan is a collectively bargained planNo
2011-03-01Plan funding arrangement – InsuranceYes
2011-03-01Plan funding arrangement – General assets of the sponsorYes
2011-03-01Plan benefit arrangement – InsuranceYes
2011-03-01Plan benefit arrangement – General assets of the sponsorYes
2009: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-03-01Type of plan entitySingle employer plan
2009-03-01Submission has been amendedNo
2009-03-01This submission is the final filingNo
2009-03-01This return/report is a short plan year return/report (less than 12 months)No
2009-03-01Plan is a collectively bargained planNo
2009-03-01Plan funding arrangement – InsuranceYes
2009-03-01Plan funding arrangement – General assets of the sponsorYes
2009-03-01Plan benefit arrangement – InsuranceYes
2009-03-01Plan benefit arrangement – General assets of the sponsorYes
2008: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2008 form 5500 responses
2008-03-01Type of plan entitySingle employer plan
2008-03-01Submission has been amendedNo
2008-03-01This submission is the final filingNo
2008-03-01This return/report is a short plan year return/report (less than 12 months)No
2008-03-01Plan is a collectively bargained planNo
2008-03-01Plan funding arrangement – InsuranceYes
2008-03-01Plan funding arrangement – General assets of the sponsorYes
2008-03-01Plan benefit arrangement – InsuranceYes
2008-03-01Plan benefit arrangement – General assets of the sponsorYes
2007: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2007 form 5500 responses
2007-03-01Type of plan entitySingle employer plan
2007-03-01Submission has been amendedNo
2007-03-01This submission is the final filingNo
2007-03-01This return/report is a short plan year return/report (less than 12 months)No
2007-03-01Plan is a collectively bargained planNo
2007-03-01Plan funding arrangement – InsuranceYes
2007-03-01Plan funding arrangement – General assets of the sponsorYes
2007-03-01Plan benefit arrangement – InsuranceYes
2007-03-01Plan benefit arrangement – General assets of the sponsorYes
2006: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2006 form 5500 responses
2006-03-01Type of plan entitySingle employer plan
2006-03-01Submission has been amendedNo
2006-03-01This submission is the final filingNo
2006-03-01This return/report is a short plan year return/report (less than 12 months)No
2006-03-01Plan is a collectively bargained planNo
2006-03-01Plan funding arrangement – InsuranceYes
2006-03-01Plan funding arrangement – General assets of the sponsorYes
2006-03-01Plan benefit arrangement – InsuranceYes
2006-03-01Plan benefit arrangement – General assets of the sponsorYes
2005: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2005 form 5500 responses
2005-03-01Type of plan entitySingle employer plan
2005-03-01Submission has been amendedNo
2005-03-01This submission is the final filingNo
2005-03-01This return/report is a short plan year return/report (less than 12 months)No
2005-03-01Plan is a collectively bargained planNo
2005-03-01Plan funding arrangement – InsuranceYes
2005-03-01Plan funding arrangement – General assets of the sponsorYes
2005-03-01Plan benefit arrangement – InsuranceYes
2005-03-01Plan benefit arrangement – General assets of the sponsorYes
2004: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2004 form 5500 responses
2004-03-01Type of plan entitySingle employer plan
2004-03-01Submission has been amendedNo
2004-03-01This submission is the final filingNo
2004-03-01This return/report is a short plan year return/report (less than 12 months)No
2004-03-01Plan is a collectively bargained planNo
2004-03-01Plan funding arrangement – InsuranceYes
2004-03-01Plan funding arrangement – General assets of the sponsorYes
2004-03-01Plan benefit arrangement – InsuranceYes
2004-03-01Plan benefit arrangement – General assets of the sponsorYes
2003: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2003 form 5500 responses
2003-03-01Type of plan entitySingle employer plan
2003-03-01Submission has been amendedNo
2003-03-01This submission is the final filingNo
2003-03-01This return/report is a short plan year return/report (less than 12 months)No
2003-03-01Plan is a collectively bargained planNo
2003-03-01Plan funding arrangement – InsuranceYes
2003-03-01Plan funding arrangement – General assets of the sponsorYes
2003-03-01Plan benefit arrangement – InsuranceYes
2003-03-01Plan benefit arrangement – General assets of the sponsorYes
2002: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2002 form 5500 responses
2002-03-01Type of plan entitySingle employer plan
2002-03-01Submission has been amendedNo
2002-03-01This submission is the final filingNo
2002-03-01This return/report is a short plan year return/report (less than 12 months)No
2002-03-01Plan is a collectively bargained planNo
2002-03-01Plan funding arrangement – InsuranceYes
2002-03-01Plan funding arrangement – General assets of the sponsorYes
2002-03-01Plan benefit arrangement – InsuranceYes
2002-03-01Plan benefit arrangement – General assets of the sponsorYes
2001: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2001 form 5500 responses
2001-03-01Type of plan entitySingle employer plan
2001-03-01Submission has been amendedNo
2001-03-01This submission is the final filingNo
2001-03-01This return/report is a short plan year return/report (less than 12 months)No
2001-03-01Plan is a collectively bargained planNo
2001-03-01Plan funding arrangement – InsuranceYes
2001-03-01Plan funding arrangement – General assets of the sponsorYes
2001-03-01Plan benefit arrangement – InsuranceYes
2001-03-01Plan benefit arrangement – General assets of the sponsorYes
2000: GOLDEN STATE DRILLING, INC. HEALTH AND WELFARE BENEFIT PLAN 2000 form 5500 responses
2000-03-01Type of plan entitySingle employer plan
2000-03-01Submission has been amendedNo
2000-03-01This submission is the final filingNo
2000-03-01This return/report is a short plan year return/report (less than 12 months)No
2000-03-01Plan is a collectively bargained planNo
2000-03-01Plan funding arrangement – InsuranceYes
2000-03-01Plan funding arrangement – General assets of the sponsorYes
2000-03-01Plan benefit arrangement – InsuranceYes
2000-03-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number803239G
Policy instance 3
Insurance contract or identification number803239G
Number of Individuals Covered85
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $1,176
Total amount of fees paid to insurance companyUSD $539
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $11,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,829
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-015348
Policy instance 2
Insurance contract or identification number010-015348
Number of Individuals Covered191
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $1,387
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $69,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,387
Amount paid for insurance broker fees0
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0064437
Policy instance 1
Insurance contract or identification numberW0064437
Number of Individuals Covered232
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $43,953
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $828,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees43953
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number803239G
Policy instance 3
Insurance contract or identification number803239G
Number of Individuals Covered275
Insurance policy start date2019-03-01
Insurance policy end date2020-02-28
Total amount of commissions paid to insurance brokerUSD $2,355
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $23,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,355
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-015348
Policy instance 2
Insurance contract or identification number010-015348
Number of Individuals Covered446
Insurance policy start date2019-03-01
Insurance policy end date2020-02-28
Total amount of commissions paid to insurance brokerUSD $3,185
Total amount of fees paid to insurance companyUSD $2,363
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $200,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,185
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0064437
Policy instance 1
Insurance contract or identification numberW0064437
Number of Individuals Covered339
Insurance policy start date2019-03-01
Insurance policy end date2020-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $115,146
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,119,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees82133
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0064437
Policy instance 3
Insurance contract or identification numberW0064437
Number of Individuals Covered247
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $98,140
Total amount of fees paid to insurance companyUSD $31,209
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,962,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $98,140
Amount paid for insurance broker fees31209
Additional information about fees paid to insurance brokerBONUS OVERRIDE & GIFTS
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0064437
Policy instance 1
Insurance contract or identification numberW0064437
Number of Individuals Covered247
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $98,140
Total amount of fees paid to insurance companyUSD $31,209
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,962,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $98,140
Amount paid for insurance broker fees31209
Additional information about fees paid to insurance brokerBONUS OVERRIDE & GIFTS
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010015348
Policy instance 2
Insurance contract or identification number010015348
Number of Individuals Covered255
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $5,762
Total amount of fees paid to insurance companyUSD $1,512
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $178,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,762
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number08051940284778
Policy instance 3
Insurance contract or identification number08051940284778
Number of Individuals Covered275
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $2,131
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,131
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number08051940284778
Policy instance 1
Insurance contract or identification number08051940284778
Number of Individuals Covered275
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $2,131
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,131
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0805194
Policy instance 3
Insurance contract or identification number0805194
Number of Individuals Covered250
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $2,632
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,442
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NATIONAL INC
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0064437
Policy instance 2
Insurance contract or identification numberW0064437
Number of Individuals Covered199
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $81,223
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,624,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,223
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NATIONAL,INC
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010015348
Policy instance 1
Insurance contract or identification number010015348
Number of Individuals Covered206
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $2,083
Total amount of fees paid to insurance companyUSD $1,919
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $159,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,083
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SVCS USA INC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0805194HNO
Policy instance 1
Insurance contract or identification number0805194HNO
Number of Individuals Covered335
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $140,954
Total amount of fees paid to insurance companyUSD $9,646
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,912,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $140,954
Amount paid for insurance broker fees9646
Additional information about fees paid to insurance broker2014/2015 PPP ENGAGEMENT CREDIT
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES USA
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0805194
Policy instance 2
Insurance contract or identification number0805194
Number of Individuals Covered18
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $7,067
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $154,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,067
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES, USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number865315G
Policy instance 3
Insurance contract or identification number865315G
Number of Individuals Covered375
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $2,546
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $25,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,546
Amount paid for insurance broker fees795
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SVCS USA INC
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010015348
Policy instance 4
Insurance contract or identification number010015348
Number of Individuals Covered418
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $3,416
Total amount of fees paid to insurance companyUSD $3,936
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $225,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,416
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SVCS USA INC
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010015348
Policy instance 4
Insurance contract or identification number010015348
Number of Individuals Covered374
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $3,962
Total amount of fees paid to insurance companyUSD $2,623
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $239,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,962
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SERVICES, USA
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0805194HNO
Policy instance 1
Insurance contract or identification number0805194HNO
Number of Individuals Covered377
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $140,900
Total amount of fees paid to insurance companyUSD $15,424
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,591,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $70,826
Amount paid for insurance broker fees15424
Additional information about fees paid to insurance broker2013/2014 MM P3 BONUS
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SERVICES USA
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number0805194
Policy instance 2
Insurance contract or identification number0805194
Number of Individuals Covered18
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $7,709
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $154,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,497
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SERVICES, USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number865315G
Policy instance 3
Insurance contract or identification number865315G
Number of Individuals Covered316
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $2,279
Total amount of fees paid to insurance companyUSD $295
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,279
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker nameWELLS FARGO INS SERVICES, USA
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010015348
Policy instance 4
Insurance contract or identification number010015348
Number of Individuals Covered317
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $3,970
Total amount of fees paid to insurance companyUSD $3,375
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $228,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees3375
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SVCS USA
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberUS400992
Policy instance 2
Insurance contract or identification numberUS400992
Number of Individuals Covered251
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $163,790
Total amount of fees paid to insurance companyUSD $11,858
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,045,619
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $163,790
Amount paid for insurance broker fees11858
Additional information about fees paid to insurance brokerMM EARLIER PREMIER PRODUCER 1/1/2013- 4/30/2013 RENEWAL BONUS; 2012 MEDICAL RETENTION SUPPL. COMPENSATION
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES USA
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0805194
Policy instance 1
Insurance contract or identification number0805194
Number of Individuals Covered18
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $8,060
Total amount of fees paid to insurance companyUSD $5,545
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $150,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,060
Amount paid for insurance broker fees5545
Additional information about fees paid to insurance brokerMM EARLY PREMIER PRODUCER 1/1/2013 - 4/30/2013 RENEWAL BONUS; 2012 MEDICAL RETENTION SUPPL. COMPENSATION
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number865315G
Policy instance 3
Insurance contract or identification number865315G
Number of Individuals Covered317
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $1,889
Total amount of fees paid to insurance companyUSD $271
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees271
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $1,889
Insurance broker nameWELLS FARGO INSURANCE SVCS USA
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number805194
Policy instance 1
Insurance contract or identification number805194
Number of Individuals Covered18
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $6,983
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $141,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,983
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SVCS USA
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberUS400992
Policy instance 2
Insurance contract or identification numberUS400992
Number of Individuals Covered312
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $137,407
Total amount of fees paid to insurance companyUSD $14,475
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,772,296
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $137,407
Amount paid for insurance broker fees14475
Additional information about fees paid to insurance broker2011 MEDICAL RETENTION SUPP COMPENSATION
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SVCS USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number865315G
Policy instance 3
Insurance contract or identification number865315G
Number of Individuals Covered325
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $1,545
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $15,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,545
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SVCS USA
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010015348
Policy instance 4
Insurance contract or identification number010015348
Number of Individuals Covered321
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $3,852
Total amount of fees paid to insurance companyUSD $3,551
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $219,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees3551
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $3,852
Insurance broker nameWELLS FARGO INS SVCS USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number865315G
Policy instance 4
Insurance contract or identification number865315G
Number of Individuals Covered321
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $1,603
Total amount of fees paid to insurance companyUSD $571
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $16,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-015348
Policy instance 3
Insurance contract or identification number010-015348
Number of Individuals Covered321
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $7,749
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $216,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberUS400992
Policy instance 2
Insurance contract or identification numberUS400992
Number of Individuals Covered303
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $117,981
Total amount of fees paid to insurance companyUSD $12,325
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,404,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number805194
Policy instance 1
Insurance contract or identification number805194
Number of Individuals Covered18
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $5,643
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $114,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number865315G
Policy instance 1
Insurance contract or identification number865315G
Number of Individuals Covered321
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $1,634
Total amount of fees paid to insurance companyUSD $5
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $21,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,634
Insurance broker organization code?3
Amount paid for insurance broker fees5
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker nameWELLS FARGO INS SVCS USA INC
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberUS400992
Policy instance 2
Insurance contract or identification numberUS400992
Number of Individuals Covered281
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $86,304
Total amount of fees paid to insurance companyUSD $34,394
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,779,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $86,304
Amount paid for insurance broker fees34394
Additional information about fees paid to insurance broker2009 NEW BUSINESS MEDICAL BONUS
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SVCS USA INC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number805194
Policy instance 3
Insurance contract or identification number805194
Number of Individuals Covered7
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $4,786
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $97,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,786
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SVCS USA INC
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-015348
Policy instance 4
Insurance contract or identification number010-015348
Number of Individuals Covered296
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $7,417
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $187,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,250
Insurance broker organization code?3
Insurance broker nameWELLS FARGO OF CA INS SVCS INC

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