CPE HR,INC. SECTION 125 PLAN 401k Plan overview

Plan Name	CPE HR,INC. SECTION 125 PLAN
Plan identification number	501

CPE HR,INC. SECTION 125 PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

GRACE DRULIAS has sponsored the creation of one or more 401k plans.

Company Name:	GRACE DRULIAS
Employer identification number (EIN):	954091491
NAIC Classification:	561300

Additional information about GRACE DRULIAS

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:	1987-03-02
Company Identification Number:	C1400674
Legal Registered Office Address:	818 West Seventh St Ste 930 Los Angeles United States of America (USA) 90017

More information about GRACE DRULIAS

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CPE HR,INC. SECTION 125 PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	FAITH BRANVOLD		GRACE DRULIAS	2018-09-28
501	2016-01-01	FAITH BRANVOLD		GRACE DRULIAS	2017-10-10
501	2015-01-01	FAITH BRANVOLD
501	2014-04-01	DANA OSAYANDE
501	2014-01-01	DANA OSAYANDE-SCOTT		GRACE DRULIAS	2015-09-29
501	2013-04-01	DANA OSAYANDE
501	2013-01-01	DANA OSAYANDE-SCOTT		DANA OSAYANDE-SCOTT	2014-11-20
501	2012-04-01	DANA OSAYANDE-SCOTT
501	2012-01-01	DANA OSAYANDE-SCOTT		GRACE DRULIAS	2013-10-09
501	2012-01-01	DANA OSAYANDE-SCOTT		GRACE DRULIAS	2014-11-18
501	2011-04-01	DANA OSAYANDE-SCOTT
501	2011-01-01	GRACE DRULIAS
501	2009-01-01	GRACE DRULIAS
501	2009-01-01	GRACE DRULIAS
501	2009-01-01	GRACE DRULIAS

Plan Statistics for CPE HR,INC. SECTION 125 PLAN

401k plan membership statisitcs for CPE HR,INC. SECTION 125 PLAN

Measure	Date	Value
2022: CPE HR,INC. SECTION 125 PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	25,892
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	25,892
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	25,892
2021: CPE HR,INC. SECTION 125 PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	20,774
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	25,892
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	25,892
2020: CPE HR,INC. SECTION 125 PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	7,276
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	20,774
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	20,774
2019: CPE HR,INC. SECTION 125 PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	5,922
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	7,276
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	7,276
2018: CPE HR,INC. SECTION 125 PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	4,696
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	6,601
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	6,601
2017: CPE HR,INC. SECTION 125 PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	4,784
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	6,199
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	6,199
2016: CPE HR,INC. SECTION 125 PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	4,137
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	6,218
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	6,218
2015: CPE HR,INC. SECTION 125 PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	3,036
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	0
2014: CPE HR,INC. SECTION 125 PLAN 2014 401k membership
Total participants, beginning-of-year	2014-04-01	586
Total number of active participants reported on line 7a of the Form 5500	2014-04-01	599
Total of all active and inactive participants	2014-04-01	599
Total participants, beginning-of-year	2014-01-01	4,620
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	0
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	0
2013: CPE HR,INC. SECTION 125 PLAN 2013 401k membership
Total participants, beginning-of-year	2013-04-01	484
Total number of active participants reported on line 7a of the Form 5500	2013-04-01	489
Total of all active and inactive participants	2013-04-01	489
Total participants, beginning-of-year	2013-01-01	3,895
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	5,698
Total of all active and inactive participants	2013-01-01	5,698
2012: CPE HR,INC. SECTION 125 PLAN 2012 401k membership
Total participants, beginning-of-year	2012-04-01	433
Total number of active participants reported on line 7a of the Form 5500	2012-04-01	427
Total of all active and inactive participants	2012-04-01	427
Total participants, beginning-of-year	2012-01-01	3,616
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	4,731
Total of all active and inactive participants	2012-01-01	4,731
2011: CPE HR,INC. SECTION 125 PLAN 2011 401k membership
Total participants, beginning-of-year	2011-04-01	354
Total number of active participants reported on line 7a of the Form 5500	2011-04-01	386
Total of all active and inactive participants	2011-04-01	386
Total participants, beginning-of-year	2011-01-01	4,359
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	4,402
Total of all active and inactive participants	2011-01-01	4,402
Total participants	2011-01-01	4,402
Number of employers contributing to the scheme	2011-01-01	1
2009: CPE HR,INC. SECTION 125 PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	4,200
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	4,134
Total of all active and inactive participants	2009-01-01	4,134
Total participants	2009-01-01	4,134

Financial Data on CPE HR,INC. SECTION 125 PLAN

Measure	Date	Value
2022 : CPE HR,INC. SECTION 125 PLAN 2022 401k financial data
Total income from all sources (including contributions)	2022-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Was this plan covered by a fidelity bond	2022-12-31	No
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Did the plan have assets held for investment	2022-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
2021 : CPE HR,INC. SECTION 125 PLAN 2021 401k financial data
Total income from all sources (including contributions)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Was this plan covered by a fidelity bond	2021-12-31	No
If this is an individual account plan, was there a blackout period	2021-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Did the plan have assets held for investment	2021-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
2020 : CPE HR,INC. SECTION 125 PLAN 2020 401k financial data
Total income from all sources (including contributions)	2020-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Was this plan covered by a fidelity bond	2020-12-31	No
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Did the plan have assets held for investment	2020-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
2013 : CPE HR,INC. SECTION 125 PLAN 2013 401k financial data
Total income from all sources (including contributions)	2013-12-31	$0
Was this plan covered by a fidelity bond	2013-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Did the plan have assets held for investment	2013-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
2012 : CPE HR,INC. SECTION 125 PLAN 2012 401k financial data
Total income from all sources (including contributions)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Was this plan covered by a fidelity bond	2012-12-31	No
If this is an individual account plan, was there a blackout period	2012-12-31	No
Funding deficiency by the employer to the plan for this plan year	2012-12-31	$-4,975,185
Amount contributed by the employer to the plan for this plan year	2012-12-31	$4,975,185
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Did the plan have assets held for investment	2012-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	KELLOGG & ANDELSON
Accountancy firm EIN	2012-12-31	952793306
2010 : CPE HR,INC. SECTION 125 PLAN 2010 401k financial data
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	KELLOGG & ANDELSON ACCOUNTANCY CORP
Accountancy firm EIN	2010-12-31	952793306

Form 5500 Responses for CPE HR,INC. SECTION 125 PLAN

2022: CPE HR,INC. SECTION 125 PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Multi-employer plan
2022-01-01	Plan is a collectively bargained plan	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: CPE HR,INC. SECTION 125 PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Multi-employer plan
2021-01-01	Plan is a collectively bargained plan	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: CPE HR,INC. SECTION 125 PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Multi-employer plan
2020-01-01	Plan is a collectively bargained plan	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: CPE HR,INC. SECTION 125 PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Multi-employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: CPE HR,INC. SECTION 125 PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Multi-employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: CPE HR,INC. SECTION 125 PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Multi-employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: CPE HR,INC. SECTION 125 PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Multi-employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: CPE HR,INC. SECTION 125 PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Multi-employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: CPE HR,INC. SECTION 125 PLAN 2014 form 5500 responses
2014-04-01	Type of plan entity	Single employer plan
2014-04-01	Submission has been amended	No
2014-04-01	This submission is the final filing	No
2014-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-04-01	Plan is a collectively bargained plan	No
2014-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014-01-01	Type of plan entity	Multi-employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: CPE HR,INC. SECTION 125 PLAN 2013 form 5500 responses
2013-04-01	Type of plan entity	Single employer plan
2013-04-01	Submission has been amended	No
2013-04-01	This submission is the final filing	No
2013-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-04-01	Plan is a collectively bargained plan	No
2013-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013-01-01	Type of plan entity	Multi-employer plan
2013-01-01	Submission has been amended	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: CPE HR,INC. SECTION 125 PLAN 2012 form 5500 responses
2012-04-01	Type of plan entity	Single employer plan
2012-04-01	Submission has been amended	No
2012-04-01	This submission is the final filing	No
2012-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-04-01	Plan is a collectively bargained plan	No
2012-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012-01-01	Type of plan entity	Multi-employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: CPE HR,INC. SECTION 125 PLAN 2011 form 5500 responses
2011-04-01	Type of plan entity	Single employer plan
2011-04-01	Submission has been amended	No
2011-04-01	This submission is the final filing	No
2011-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-04-01	Plan is a collectively bargained plan	No
2011-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011-01-01	Type of plan entity	Multi-employer plan
2011-01-01	Submission has been amended	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: CPE HR,INC. SECTION 125 PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Multi-employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5969793
Policy instance	41
Insurance contract or identification number 5969793 Number of Individuals Covered 167 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $8,551 Total amount of fees paid to insurance company USD $4,211 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,551 Amount paid for insurance broker fees 4211 Additional information about fees paid to insurance broker 4211 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS INC A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	5536970
Policy instance	13
Insurance contract or identification number 5536970 Number of Individuals Covered 3 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	KM05958849
Policy instance	14
Insurance contract or identification number KM05958849 Number of Individuals Covered 166 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $2,361 Total amount of fees paid to insurance company USD $905 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,361 Amount paid for insurance broker fees 905 Insurance broker organization code? 3
SUTTER HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15107 )
Policy contract number	152004
Policy instance	15
Insurance contract or identification number 152004 Number of Individuals Covered 72 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $30,806 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,806 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	714737
Policy instance	16
Insurance contract or identification number 714737 Number of Individuals Covered 182 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of fees paid to insurance company USD $69,571 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 69571 Insurance broker organization code? 3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	010-041014
Policy instance	17
Insurance contract or identification number 010-041014 Number of Individuals Covered 145 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $3,015 Total amount of fees paid to insurance company USD $2,662 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,015 Insurance broker organization code? 3 Amount paid for insurance broker fees 2662
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	18
Insurance contract or identification number G000702H Number of Individuals Covered 185 Insurance policy start date 2021-02-01 Insurance policy end date 2022-02-01 Total amount of commissions paid to insurance broker USD $748 Total amount of fees paid to insurance company USD $517 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $748 Amount paid for insurance broker fees 517 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	114049
Policy instance	19
Insurance contract or identification number 114049 Number of Individuals Covered 1198 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $625,522 Total amount of fees paid to insurance company USD $13,262 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $625,522 Amount paid for insurance broker fees 13262 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	39723
Policy instance	20
Insurance contract or identification number 39723 Number of Individuals Covered 306 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $161,027 Total amount of fees paid to insurance company USD $1,892 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $161,027 Amount paid for insurance broker fees 1892 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	TS05336970
Policy instance	12
Insurance contract or identification number TS05336970 Number of Individuals Covered 1926 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $24,631 Total amount of fees paid to insurance company USD $2,463 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,631 Amount paid for insurance broker fees 2463 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number	TS05336970
Policy instance	11
Insurance contract or identification number TS05336970 Number of Individuals Covered 17 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VPS 327924
Policy instance	10
Insurance contract or identification number VPS 327924 Number of Individuals Covered 25 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $1,983 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,983 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	234880
Policy instance	2
Insurance contract or identification number 234880 Number of Individuals Covered 26 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-01 Total amount of commissions paid to insurance broker USD $20,394 Total amount of fees paid to insurance company USD $134 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,394 Amount paid for insurance broker fees 134 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	G162313
Policy instance	3
Insurance contract or identification number G162313 Number of Individuals Covered 20 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $420 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $420 Insurance broker organization code? 4
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	4
Insurance contract or identification number GL 138677 Number of Individuals Covered 1302 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $29,995 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,995 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	5
Insurance contract or identification number GL 138680 Number of Individuals Covered 2913 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $8,774 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,774 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	6
Insurance contract or identification number LTD 112593 Number of Individuals Covered 759 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $3,956 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,956 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	7
Insurance contract or identification number VAR 203203 Number of Individuals Covered 901 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $3,352 Other welfare benefits provided ACCIDENTAL DEATH Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,352 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 159572
Policy instance	8
Insurance contract or identification number GL 159572 Number of Individuals Covered 346 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $1,515 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,515 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VG 187295
Policy instance	9
Insurance contract or identification number VG 187295 Number of Individuals Covered 33 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $2,886 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,886 Insurance broker organization code? 3
AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )
Policy contract number	11001-1536
Policy instance	21
Insurance contract or identification number 11001-1536 Number of Individuals Covered 106 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $1,486 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,486 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E5187638
Policy instance	22
Insurance contract or identification number E5187638 Number of Individuals Covered 113 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $3,034 Total amount of fees paid to insurance company USD $687 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,431 Amount paid for insurance broker fees 42 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30091018
Policy instance	34
Insurance contract or identification number 30091018 Number of Individuals Covered 285 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $342 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $342 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30098144
Policy instance	35
Insurance contract or identification number 30098144 Number of Individuals Covered 107 Insurance policy start date 2020-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $224 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $224 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	36
Insurance contract or identification number G0004461 Number of Individuals Covered 29 Insurance policy start date 2021-05-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $126 Total amount of fees paid to insurance company USD $29 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $126 Amount paid for insurance broker fees 29 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG04461
Policy instance	37
Insurance contract or identification number GLUG04461 Number of Individuals Covered 898 Insurance policy start date 2021-05-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $1,161 Total amount of fees paid to insurance company USD $830 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,161 Amount paid for insurance broker fees 830 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	38
Insurance contract or identification number G0004461 Number of Individuals Covered 52 Insurance policy start date 2021-05-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $3,741 Total amount of fees paid to insurance company USD $2,601 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,741 Amount paid for insurance broker fees 2601 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	917466
Policy instance	39
Insurance contract or identification number 917466 Number of Individuals Covered 498 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $317,519 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $317,519 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	5969793
Policy instance	40
Insurance contract or identification number 5969793 Number of Individuals Covered 76 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $95 Total amount of fees paid to insurance company USD $365 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $95 Amount paid for insurance broker fees 365 Insurance broker organization code? 3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	1
Insurance contract or identification number 275730 Number of Individuals Covered 2807 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $952,212 Total amount of fees paid to insurance company USD $44,223 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $952,212 Amount paid for insurance broker fees 44223 Insurance broker organization code? 3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	76724
Policy instance	33
Insurance contract or identification number 76724 Number of Individuals Covered 242 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $4,830 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,830 Insurance broker organization code? 3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	16030
Policy instance	32
Insurance contract or identification number 16030 Number of Individuals Covered 551 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $43,332 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $43,332 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	600306
Policy instance	31
Insurance contract or identification number 600306 Number of Individuals Covered 364 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-01 Total amount of commissions paid to insurance broker USD $295,469 Total amount of fees paid to insurance company USD $6,176 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $295,469 Amount paid for insurance broker fees 6176 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	00010148655
Policy instance	23
Insurance contract or identification number 00010148655 Number of Individuals Covered 144 Insurance policy start date 2021-11-01 Insurance policy end date 2022-10-31 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010148657
Policy instance	24
Insurance contract or identification number 000010148657 Number of Individuals Covered 144 Insurance policy start date 2021-11-01 Insurance policy end date 2022-10-31 Other welfare benefits provided WEEKLY INCOME Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010148656
Policy instance	25
Insurance contract or identification number 000010148656 Number of Individuals Covered 144 Insurance policy start date 2021-11-01 Insurance policy end date 2022-10-31 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TS05336970
Policy instance	26
Insurance contract or identification number TS05336970 Number of Individuals Covered 1997 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $158,359 Total amount of fees paid to insurance company USD $15,836 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $158,359 Amount paid for insurance broker fees 15836 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5958849
Policy instance	27
Insurance contract or identification number 5958849 Number of Individuals Covered 384 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $19,018 Total amount of fees paid to insurance company USD $2,010 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,018 Amount paid for insurance broker fees 2010 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	28
Insurance contract or identification number G000702H Number of Individuals Covered 41 Insurance policy start date 2021-02-01 Insurance policy end date 2022-02-01 Total amount of commissions paid to insurance broker USD $485 Total amount of fees paid to insurance company USD $549 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 549 Insurance broker organization code? 3 Commission paid to Insurance Broker USD $485
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	29
Insurance contract or identification number G000702H Number of Individuals Covered 47 Insurance policy start date 2021-02-01 Insurance policy end date 2022-02-01 Total amount of commissions paid to insurance broker USD $2,104 Total amount of fees paid to insurance company USD $1,212 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,104 Amount paid for insurance broker fees 1212 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	30
Insurance contract or identification number 227118 Number of Individuals Covered 261 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-01 Total amount of commissions paid to insurance broker USD $151,814 Total amount of fees paid to insurance company USD $5,272 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $151,814 Amount paid for insurance broker fees 5272 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	5336970
Policy instance	29
Insurance contract or identification number 5336970 Number of Individuals Covered 2022 Insurance policy start date 2020-04-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $25,173 Total amount of fees paid to insurance company USD $3,776 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,173 Amount paid for insurance broker fees 3776 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	5336970
Policy instance	30
Insurance contract or identification number 5336970 Number of Individuals Covered 11 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $11 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	5958849
Policy instance	31
Insurance contract or identification number 5958849 Number of Individuals Covered 360 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $9,232 Total amount of fees paid to insurance company USD $2,288 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,232 Amount paid for insurance broker fees 2288 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	714737
Policy instance	32
Insurance contract or identification number 714737 Number of Individuals Covered 208 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of fees paid to insurance company USD $81,293 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 81293 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	917466
Policy instance	33
Insurance contract or identification number 917466 Number of Individuals Covered 525 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $444,948 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $444,948 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	34
Insurance contract or identification number G000702H Number of Individuals Covered 184 Insurance policy start date 2020-02-01 Insurance policy end date 2021-02-01 Total amount of commissions paid to insurance broker USD $821 Total amount of fees paid to insurance company USD $667 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $821 Amount paid for insurance broker fees 667 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	35
Insurance contract or identification number G0004461 Number of Individuals Covered 494 Insurance policy start date 2020-05-01 Insurance policy end date 2021-05-01 Total amount of commissions paid to insurance broker USD $1,411 Total amount of fees paid to insurance company USD $913 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,411 Amount paid for insurance broker fees 913 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12214263
Policy instance	36
Insurance contract or identification number 12214263 Number of Individuals Covered 3314 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $17,914 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,914 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number	5336970
Policy instance	28
Insurance contract or identification number 5336970 Number of Individuals Covered 6 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $19 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VPS 327924
Policy instance	27
Insurance contract or identification number VPS 327924 Number of Individuals Covered 31 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $872 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $872 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 160682
Policy instance	26
Insurance contract or identification number GL 160682 Number of Individuals Covered 324 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $6,475 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,475 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	G162313
Policy instance	18
Insurance contract or identification number G162313 Number of Individuals Covered 101 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $815 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $815 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	19
Insurance contract or identification number GL 138677 Number of Individuals Covered 2423 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $33,887 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,887 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	20
Insurance contract or identification number GL 138680 Number of Individuals Covered 3101 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $12,753 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,753 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	21
Insurance contract or identification number LTD 112593 Number of Individuals Covered 860 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $5,480 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,480 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	22
Insurance contract or identification number VAR 203203 Number of Individuals Covered 873 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $3,037 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,037 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 159572
Policy instance	23
Insurance contract or identification number GL 159572 Number of Individuals Covered 139 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $1,423 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,423 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VG 187295
Policy instance	24
Insurance contract or identification number VG 187295 Number of Individuals Covered 63 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $2,654 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,654 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 208605
Policy instance	25
Insurance contract or identification number VAR 208605 Number of Individuals Covered 272 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $334 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $334 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30091018
Policy instance	38
Insurance contract or identification number 30091018 Number of Individuals Covered 382 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $1,198 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,198 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12236504
Policy instance	37
Insurance contract or identification number 12236504 Number of Individuals Covered 521 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $2,135 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,135 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	39723
Policy instance	10
Insurance contract or identification number 39723 Number of Individuals Covered 242 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $76,170 Total amount of fees paid to insurance company USD $316 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $76,170 Amount paid for insurance broker fees 316 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	11
Insurance contract or identification number 227118 Number of Individuals Covered 358 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $228,111 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $228,111 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	600306
Policy instance	12
Insurance contract or identification number 600306 Number of Individuals Covered 506 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $362,999 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $362,999 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010148657
Policy instance	14
Insurance contract or identification number 000010148657 Number of Individuals Covered 151 Insurance policy start date 2019-11-01 Insurance policy end date 2020-10-31 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010148656
Policy instance	15
Insurance contract or identification number 000010148656 Number of Individuals Covered 151 Insurance policy start date 2019-11-01 Insurance policy end date 2020-10-31 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5336970
Policy instance	16
Insurance contract or identification number 5336970 Number of Individuals Covered 1441 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $136,192 Total amount of fees paid to insurance company USD $20,450 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $136,192 Amount paid for insurance broker fees 21 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010148655
Policy instance	13
Insurance contract or identification number 000010148655 Number of Individuals Covered 151 Insurance policy start date 2019-11-01 Insurance policy end date 2020-10-31 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5958849
Policy instance	17
Insurance contract or identification number 5958849 Number of Individuals Covered 633 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $30,404 Total amount of fees paid to insurance company USD $16,150 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,404 Amount paid for insurance broker fees 21 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	114049
Policy instance	9
Insurance contract or identification number 114049 Number of Individuals Covered 1698 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $477,561 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $477,561 Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number
Policy instance	8
Number of Individuals Covered 167 Insurance policy start date 2020-03-01 Insurance policy end date 2021-02-28 Total amount of commissions paid to insurance broker USD $48,891 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $48,891 Insurance broker organization code? 3
SUTTER HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15107 )
Policy contract number	152004
Policy instance	39
Insurance contract or identification number 152004 Number of Individuals Covered 82 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $34,150 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,150 Insurance broker organization code? 3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	010-041014
Policy instance	1
Insurance contract or identification number 010-041014 Number of Individuals Covered 301 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $5,310 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,967 Insurance broker organization code? 3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	2
Insurance contract or identification number 275730 Number of Individuals Covered 2610 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $948,730 Total amount of fees paid to insurance company USD $45,285 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $948,730 Amount paid for insurance broker fees 45285 Insurance broker organization code? 3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	278917
Policy instance	3
Insurance contract or identification number 278917 Number of Individuals Covered 7 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,996 Total amount of fees paid to insurance company USD $733 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,996 Amount paid for insurance broker fees 733 Insurance broker organization code? 3
ANTHEM BLUE CROSS (National Association of Insurance Commissioners NAIC id number: )
Policy contract number	282901
Policy instance	4
Insurance contract or identification number 282901 Number of Individuals Covered 136 Insurance policy start date 2020-02-01 Insurance policy end date 2021-01-31 Total amount of commissions paid to insurance broker USD $40,199 Total amount of fees paid to insurance company USD $11,048 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $40,199 Amount paid for insurance broker fees 11048 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7910284
Policy instance	5
Insurance contract or identification number E7910284 Number of Individuals Covered 3 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $77 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $56 Insurance broker organization code? 3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	16030
Policy instance	6
Insurance contract or identification number 16030 Number of Individuals Covered 699 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $53,138 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $53,138 Insurance broker organization code? 3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	76724
Policy instance	7
Insurance contract or identification number 76724 Number of Individuals Covered 344 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $7,186 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,186 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	600306
Policy instance	12
Insurance contract or identification number 600306 Number of Individuals Covered 597 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $398,047 Total amount of fees paid to insurance company USD $5,069 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $398,047 Amount paid for insurance broker fees 5069 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TS05336970
Policy instance	13
Insurance contract or identification number TS05336970 Number of Individuals Covered 1665 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $161,271 Total amount of fees paid to insurance company USD $20,201 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $161,271 Amount paid for insurance broker fees 20201 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5958849
Policy instance	14
Insurance contract or identification number 5958849 Number of Individuals Covered 935 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-20 Total amount of commissions paid to insurance broker USD $29,788 Total amount of fees paid to insurance company USD $11,466 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,788 Amount paid for insurance broker fees 11466 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	G 162313
Policy instance	15
Insurance contract or identification number G 162313 Number of Individuals Covered 101 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $1,439 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,439 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	16
Insurance contract or identification number GL 138677 Number of Individuals Covered 1325 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $40,208 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $40,208 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	17
Insurance contract or identification number GL 138680 Number of Individuals Covered 3609 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $15,927 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,927 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	5336970
Policy instance	25
Insurance contract or identification number 5336970 Number of Individuals Covered 10 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	11
Insurance contract or identification number 227118 Number of Individuals Covered 523 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $225,073 Total amount of fees paid to insurance company USD $4,208 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $225,073 Amount paid for insurance broker fees 4208 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	39723
Policy instance	10
Insurance contract or identification number 39723 Number of Individuals Covered 128 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-30 Total amount of commissions paid to insurance broker USD $53,089 Total amount of fees paid to insurance company USD $1,062 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $53,089 Amount paid for insurance broker fees 1062 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	114049
Policy instance	9
Insurance contract or identification number 114049 Number of Individuals Covered 1037 Insurance policy start date 2019-04-01 Insurance policy end date 3030-03-30 Total amount of commissions paid to insurance broker USD $383,861 Total amount of fees paid to insurance company USD $8,355 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $383,861 Amount paid for insurance broker fees 8355 Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number
Policy instance	8
Number of Individuals Covered 138 Insurance policy start date 2019-02-01 Insurance policy end date 2020-01-31 Total amount of commissions paid to insurance broker USD $36,825 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $36,825 Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number
Policy instance	7
Number of Individuals Covered 163 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $52,601 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $52,601 Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	LB006B/LB006A
Policy instance	6
Insurance contract or identification number LB006B/LB006A Number of Individuals Covered 60 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $17,084 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,084 Insurance broker organization code? 3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number
Policy instance	5
Number of Individuals Covered 435 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $7,899 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,899 Insurance broker organization code? 3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	16030
Policy instance	4
Insurance contract or identification number 16030 Number of Individuals Covered 813 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $57,657 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $57,657 Insurance broker organization code? 3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	2
Insurance contract or identification number 275730 Number of Individuals Covered 2358 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,029,494 Total amount of fees paid to insurance company USD $11,018 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,029,494 Amount paid for insurance broker fees 11018 Insurance broker organization code? 3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	276432
Policy instance	3
Insurance contract or identification number 276432 Number of Individuals Covered 98 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $54,409 Total amount of fees paid to insurance company USD $22,506 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $54,409 Amount paid for insurance broker fees 743 Insurance broker organization code? 3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	010-041014
Policy instance	1
Insurance contract or identification number 010-041014 Number of Individuals Covered 352 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $7,271 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,165 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	5336970
Policy instance	24
Insurance contract or identification number 5336970 Number of Individuals Covered 1982 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $28,437 Total amount of fees paid to insurance company USD $3,559 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,437 Amount paid for insurance broker fees 3559 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number	5336970
Policy instance	23
Insurance contract or identification number 5336970 Number of Individuals Covered 14 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VPS 327924
Policy instance	22
Insurance contract or identification number VPS 327924 Number of Individuals Covered 38 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $1,684 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,684 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VG 187295
Policy instance	21
Insurance contract or identification number VG 187295 Number of Individuals Covered 59 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $2,374 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,374 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 159572
Policy instance	20
Insurance contract or identification number GL 159572 Number of Individuals Covered 314 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $1,181 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,181 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG04461
Policy instance	32
Insurance contract or identification number GLUG04461 Number of Individuals Covered 834 Insurance policy start date 2019-05-01 Insurance policy end date 2020-05-01 Total amount of commissions paid to insurance broker USD $1,612 Total amount of fees paid to insurance company USD $1,086 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,612 Amount paid for insurance broker fees 1086 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	19
Insurance contract or identification number VAR 203203 Number of Individuals Covered 1117 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $3,761 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,761 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	18
Insurance contract or identification number LTD 112593 Number of Individuals Covered 1048 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $7,074 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,074 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	5958849
Policy instance	26
Insurance contract or identification number 5958849 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $449 Total amount of fees paid to insurance company USD $191 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $449 Amount paid for insurance broker fees 191 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12214263
Policy instance	33
Insurance contract or identification number 12214263 Number of Individuals Covered 2341 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $13,134 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,134 Insurance broker organization code? 3
SUTTER HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15107 )
Policy contract number	152004
Policy instance	27
Insurance contract or identification number 152004 Number of Individuals Covered 72 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $21,382 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,382 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	917466
Policy instance	28
Insurance contract or identification number 917466 Number of Individuals Covered 571 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $381,922 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $381,922 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	29
Insurance contract or identification number G000702H Number of Individuals Covered 84 Insurance policy start date 2019-02-01 Insurance policy end date 2020-02-01 Total amount of commissions paid to insurance broker USD $3,080 Total amount of fees paid to insurance company USD $759 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,310 Amount paid for insurance broker fees 759 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0702H
Policy instance	30
Insurance contract or identification number GVTL0702H Number of Individuals Covered 57 Insurance policy start date 2019-02-01 Insurance policy end date 2020-02-02 Total amount of commissions paid to insurance broker USD $1,776 Total amount of fees paid to insurance company USD $1,405 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,776 Amount paid for insurance broker fees 1405 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL04461
Policy instance	31
Insurance contract or identification number GVTL04461 Number of Individuals Covered 148 Insurance policy start date 2019-05-01 Insurance policy end date 2020-05-01 Total amount of commissions paid to insurance broker USD $4,070 Total amount of fees paid to insurance company USD $3,118 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,070 Amount paid for insurance broker fees 3118 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0702H
Policy instance	36
Insurance contract or identification number GLUG0702H Number of Individuals Covered 260 Insurance policy start date 2019-02-01 Insurance policy end date 2020-01-02 Total amount of commissions paid to insurance broker USD $958 Total amount of fees paid to insurance company USD $699 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $958 Amount paid for insurance broker fees 699 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12236504
Policy instance	34
Insurance contract or identification number 12236504 Number of Individuals Covered 585 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $2,225 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,225 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30091018
Policy instance	35
Insurance contract or identification number 30091018 Number of Individuals Covered 512 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $2,050 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,050 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0702H
Policy instance	24
Insurance contract or identification number GUC0702H Number of Individuals Covered 292 Insurance policy start date 2018-02-01 Insurance policy end date 2019-02-01 Total amount of commissions paid to insurance broker USD $1,935 Total amount of fees paid to insurance company USD $799 Other welfare benefits provided PREFERRED CHOICE VOLUNTARY STD Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $977 Amount paid for insurance broker fees 799 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	G 162313
Policy instance	13
Insurance contract or identification number G 162313 Number of Individuals Covered 332 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $2,659 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,659 Insurance broker organization code? 3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	76724
Policy instance	21
Insurance contract or identification number 76724 Number of Individuals Covered 323 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $8,961 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,961 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7910284
Policy instance	39
Insurance contract or identification number E7910284 Number of Individuals Covered 3 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $75 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $54 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	148655
Policy instance	19
Insurance contract or identification number 148655 Number of Individuals Covered 145 Insurance policy start date 2018-11-01 Insurance policy end date 2019-10-31 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number	TS05336970
Policy instance	18
Insurance contract or identification number TS05336970 Number of Individuals Covered 17 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	17
Insurance contract or identification number VAR 203203 Number of Individuals Covered 734 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $5,579 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,579 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	15
Insurance contract or identification number GL 138680 Number of Individuals Covered 4078 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $18,711 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,711 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	14
Insurance contract or identification number GL 138677 Number of Individuals Covered 1343 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $46,343 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $46,343 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	71437
Policy instance	12
Insurance contract or identification number 71437 Number of Individuals Covered 229 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of fees paid to insurance company USD $83,273 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 83273 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30019646
Policy instance	11
Insurance contract or identification number 30019646 Number of Individuals Covered 121 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $1,099 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,099 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12236504
Policy instance	10
Insurance contract or identification number 12236504 Number of Individuals Covered 597 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $2,253 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,253 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TS05336970
Policy instance	9
Insurance contract or identification number TS05336970 Number of Individuals Covered 2597 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-30 Total amount of commissions paid to insurance broker USD $32,007 Total amount of fees paid to insurance company USD $7,664 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32,007 Amount paid for insurance broker fees 7664 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	600306
Policy instance	8
Insurance contract or identification number 600306 Number of Individuals Covered 675 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $284,584 Total amount of fees paid to insurance company USD $6,465 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $284,584 Amount paid for insurance broker fees 6465 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	114049
Policy instance	7
Insurance contract or identification number 114049 Number of Individuals Covered 1065 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-30 Total amount of commissions paid to insurance broker USD $389,412 Total amount of fees paid to insurance company USD $10,489 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $389,412 Amount paid for insurance broker fees 10489 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	39723
Policy instance	6
Insurance contract or identification number 39723 Number of Individuals Covered 109 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-30 Total amount of commissions paid to insurance broker USD $57,157 Total amount of fees paid to insurance company USD $1,423 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $57,157 Amount paid for insurance broker fees 1423 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	5
Insurance contract or identification number 227118 Number of Individuals Covered 483 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $156,040 Total amount of fees paid to insurance company USD $4,571 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $156,040 Amount paid for insurance broker fees 4571 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	148656
Policy instance	20
Insurance contract or identification number 148656 Number of Individuals Covered 145 Insurance policy start date 2018-11-01 Insurance policy end date 2019-10-31 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	16030
Policy instance	22
Insurance contract or identification number 16030 Number of Individuals Covered 500 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $59,180 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $59,180 Insurance broker organization code? 3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	278917
Policy instance	23
Insurance contract or identification number 278917 Number of Individuals Covered 125 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $12,173 Total amount of fees paid to insurance company USD $1,428 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,173 Amount paid for insurance broker fees 1428 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VPS 327924
Policy instance	38
Insurance contract or identification number VPS 327924 Number of Individuals Covered 37 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $505 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $505
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VG 187295
Policy instance	37
Insurance contract or identification number VG 187295 Number of Individuals Covered 57 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $2,342 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,342
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5958849
Policy instance	36
Insurance contract or identification number 5958849 Number of Individuals Covered 1739 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $182,692 Total amount of fees paid to insurance company USD $39,581 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $182,692 Amount paid for insurance broker fees 39581
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 159572
Policy instance	35
Insurance contract or identification number GL 159572 Number of Individuals Covered 358 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $1,071 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,071
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	17269A
Policy instance	34
Insurance contract or identification number 17269A Number of Individuals Covered 157 Insurance policy start date 2018-02-01 Insurance policy end date 2019-01-31 Total amount of commissions paid to insurance broker USD $37,974 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $37,974 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G00070211
Policy instance	32
Insurance contract or identification number G00070211 Number of Individuals Covered 76 Insurance policy start date 2018-02-01 Insurance policy end date 2019-02-01 Total amount of commissions paid to insurance broker USD $1,978 Total amount of fees paid to insurance company USD $1,554 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,978 Amount paid for insurance broker fees 1554 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10148657
Policy instance	31
Insurance contract or identification number 10148657 Number of Individuals Covered 145 Insurance policy start date 2018-11-01 Insurance policy end date 2019-10-31 Other welfare benefits provided WEEKLY INCOME Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	LB006B, LB006A
Policy instance	30
Insurance contract or identification number LB006B, LB006A Number of Individuals Covered 87 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $19,468 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,468 Insurance broker organization code? 3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	010-041014
Policy instance	29
Insurance contract or identification number 010-041014 Number of Individuals Covered 32 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $3,021 Total amount of fees paid to insurance company USD $3,166 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 3166 Insurance broker organization code? 3 Commission paid to Insurance Broker USD $3,021
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL04461
Policy instance	28
Insurance contract or identification number GVTL04461 Number of Individuals Covered 149 Insurance policy start date 2018-05-01 Insurance policy end date 2019-05-01 Total amount of commissions paid to insurance broker USD $404 Total amount of fees paid to insurance company USD $3,102 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $404 Amount paid for insurance broker fees 3102 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL04461
Policy instance	27
Insurance contract or identification number GVTL04461 Number of Individuals Covered 1232 Insurance policy start date 2018-05-01 Insurance policy end date 2019-05-01 Total amount of commissions paid to insurance broker USD $1,485 Total amount of fees paid to insurance company USD $1,020 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,485 Amount paid for insurance broker fees 1020 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	TS05336970
Policy instance	26
Insurance contract or identification number TS05336970 Number of Individuals Covered 3 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0702H
Policy instance	25
Insurance contract or identification number GVTL0702H Number of Individuals Covered 95 Insurance policy start date 2018-02-01 Insurance policy end date 2019-02-01 Total amount of commissions paid to insurance broker USD $2,214 Total amount of fees paid to insurance company USD $687 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,214 Amount paid for insurance broker fees 687 Insurance broker organization code? 3
ANTHEM BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	4
Insurance contract or identification number 275730 Number of Individuals Covered 1717 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $891,652 Total amount of fees paid to insurance company USD $26,891 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $569,912 Amount paid for insurance broker fees 7527 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	16
Insurance contract or identification number LTD 112593 Number of Individuals Covered 1327 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $9,948 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,948 Insurance broker organization code? 3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	276432
Policy instance	3
Insurance contract or identification number 276432 Number of Individuals Covered 57 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $40,881 Total amount of fees paid to insurance company USD $18,156 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $27,519 Amount paid for insurance broker fees 528 Insurance broker organization code? 3
ANTHEM BLUE CROSS (National Association of Insurance Commissioners NAIC id number: )
Policy contract number	277165
Policy instance	1
Insurance contract or identification number 277165 Number of Individuals Covered 274 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $127,062 Total amount of fees paid to insurance company USD $3,149 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $96,576 Amount paid for insurance broker fees 541 Insurance broker organization code? 3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	W0051511
Policy instance	2
Insurance contract or identification number W0051511 Number of Individuals Covered 276 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $277,334 Health Insurance Welfare Benefit Yes Other welfare benefits provided DRUG Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $277,334 Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	77033A
Policy instance	33
Insurance contract or identification number 77033A Number of Individuals Covered 193 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $57,389 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $57,389 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	39723
Policy instance	7
Insurance contract or identification number 39723 Number of Individuals Covered 116 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-30 Total amount of commissions paid to insurance broker USD $54,158 Total amount of fees paid to insurance company USD $1,480 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $54,158 Amount paid for insurance broker fees 1480 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	17
Insurance contract or identification number LTD 112593 Number of Individuals Covered 1167 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $10,314 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,314 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	18
Insurance contract or identification number VAR 203203 Number of Individuals Covered 916 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $2,493 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,493 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	15
Insurance contract or identification number GL 138677 Number of Individuals Covered 1281 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $43,210 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $43,210 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10170333
Policy instance	19
Insurance contract or identification number 10170333 Number of Individuals Covered 300 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $225 Total amount of fees paid to insurance company USD $-1,610 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Insurance broker organization code? 3 Commission paid to Insurance Broker USD $225 Amount paid for insurance broker fees -1610
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	148655
Policy instance	20
Insurance contract or identification number 148655 Number of Individuals Covered 144 Insurance policy start date 2017-11-01 Insurance policy end date 2018-10-31 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	G 162313
Policy instance	14
Insurance contract or identification number G 162313 Number of Individuals Covered 351 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $3,387 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,387 Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	16
Insurance contract or identification number GL 138680 Number of Individuals Covered 248 Insurance policy start date 2017-09-01 Insurance policy end date 2018-08-31 Total amount of commissions paid to insurance broker USD $694 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $694 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12214263
Policy instance	13
Insurance contract or identification number 12214263 Number of Individuals Covered 3198 Insurance policy start date 2018-01-01 Insurance policy end date 2018-01-23 Total amount of commissions paid to insurance broker USD $18,778 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,778 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10148657
Policy instance	32
Insurance contract or identification number 10148657 Number of Individuals Covered 143 Insurance policy start date 2017-11-01 Insurance policy end date 2018-10-31 Other welfare benefits provided WEEKLY INCOME Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	W0051511
Policy instance	3
Insurance contract or identification number W0051511 Number of Individuals Covered 150 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $292,337 Health Insurance Welfare Benefit Yes Other welfare benefits provided DRUG Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $292,337 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	714737
Policy instance	2
Insurance contract or identification number 714737 Number of Individuals Covered 330 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of fees paid to insurance company USD $78,183 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 78183 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	600306
Policy instance	9
Insurance contract or identification number 600306 Number of Individuals Covered 629 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $291,977 Total amount of fees paid to insurance company USD $7,017 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $291,977 Amount paid for insurance broker fees 7017 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	114049
Policy instance	8
Insurance contract or identification number 114049 Number of Individuals Covered 1074 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-30 Total amount of commissions paid to insurance broker USD $371,776 Total amount of fees paid to insurance company USD $11,387 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $371,776 Amount paid for insurance broker fees 11387 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number	TS05336970
Policy instance	10
Insurance contract or identification number TS05336970 Number of Individuals Covered 19 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30019646
Policy instance	11
Insurance contract or identification number 30019646 Number of Individuals Covered 131 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $1,111 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,111 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12236504
Policy instance	12
Insurance contract or identification number 12236504 Number of Individuals Covered 601 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $2,230 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,230 Insurance broker organization code? 3
ANTHEM BLUE CROSS (National Association of Insurance Commissioners NAIC id number: )
Policy contract number	277165
Policy instance	1
Insurance contract or identification number 277165 Number of Individuals Covered 250 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $150,462 Total amount of fees paid to insurance company USD $10,307 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $150,462 Amount paid for insurance broker fees 10307 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	148656
Policy instance	21
Insurance contract or identification number 148656 Number of Individuals Covered 143 Insurance policy start date 2017-11-01 Insurance policy end date 2018-10-31 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL04461
Policy instance	29
Insurance contract or identification number GVTL04461 Number of Individuals Covered 153 Insurance policy start date 2017-05-01 Insurance policy end date 2018-05-01 Total amount of commissions paid to insurance broker USD $4,533 Total amount of fees paid to insurance company USD $3,735 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,533 Amount paid for insurance broker fees 3735 Insurance broker organization code? 3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	010-041014
Policy instance	30
Insurance contract or identification number 010-041014 Number of Individuals Covered 332 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $86,397 Total amount of fees paid to insurance company USD $4,319 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $86,397 Amount paid for insurance broker fees 4319 Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	LB006B, LB006A
Policy instance	31
Insurance contract or identification number LB006B, LB006A Number of Individuals Covered 100 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $21,057 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,057 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10170334
Policy instance	33
Insurance contract or identification number 10170334 Number of Individuals Covered 22 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $3,196 Total amount of fees paid to insurance company USD $-2,790 Other welfare benefits provided WEEKLY INCOME Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,196 Insurance broker organization code? 3 Amount paid for insurance broker fees -2790
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000
Policy instance	34
Insurance contract or identification number 400001000 Number of Individuals Covered 100 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $1,721 Total amount of fees paid to insurance company USD $-822 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,721 Insurance broker organization code? 3 Amount paid for insurance broker fees -822
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	77033A
Policy instance	38
Insurance contract or identification number 77033A Number of Individuals Covered 183 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $55,575 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $55,575 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG04461
Policy instance	37
Insurance contract or identification number GLUG04461 Number of Individuals Covered 589 Insurance policy start date 2017-05-01 Insurance policy end date 2018-05-01 Total amount of commissions paid to insurance broker USD $1,428 Total amount of fees paid to insurance company USD $1,086 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,428 Amount paid for insurance broker fees 1086 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	TS05336970
Policy instance	40
Insurance contract or identification number TS05336970 Number of Individuals Covered 2 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	6
Insurance contract or identification number 227118 Number of Individuals Covered 505 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-30 Total amount of commissions paid to insurance broker USD $172,506 Total amount of fees paid to insurance company USD $5,404 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $172,506 Amount paid for insurance broker fees 5404 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL04461
Policy instance	28
Insurance contract or identification number GVTL04461 Number of Individuals Covered 589 Insurance policy start date 2017-05-01 Insurance policy end date 2018-05-01 Total amount of commissions paid to insurance broker USD $1,428 Total amount of fees paid to insurance company USD $1,086 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,428 Amount paid for insurance broker fees 1086 Insurance broker organization code? 3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	276432
Policy instance	4
Insurance contract or identification number 276432 Number of Individuals Covered 120 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $56,870 Total amount of fees paid to insurance company USD $27,374 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $56,870 Insurance broker organization code? 3 Amount paid for insurance broker fees 22748
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	76724
Policy instance	22
Insurance contract or identification number 76724 Number of Individuals Covered 555 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $9,350 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,350 Insurance broker organization code? 3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	16030
Policy instance	23
Insurance contract or identification number 16030 Number of Individuals Covered 880 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $59,839 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $59,839 Insurance broker organization code? 3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	278917
Policy instance	24
Insurance contract or identification number 278917 Number of Individuals Covered 125 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $12,335 Total amount of fees paid to insurance company USD $1,642 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,335 Amount paid for insurance broker fees 1642 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0702H
Policy instance	25
Insurance contract or identification number GUC0702H Number of Individuals Covered 81 Insurance policy start date 2017-02-01 Insurance policy end date 2018-02-01 Total amount of commissions paid to insurance broker USD $2,507 Total amount of fees paid to insurance company USD $365 Other welfare benefits provided PREFERRED CHOICE VOLUNTARY STD Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,880 Amount paid for insurance broker fees 365 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0702H
Policy instance	26
Insurance contract or identification number GVTL0702H Number of Individuals Covered 338 Insurance policy start date 2017-02-01 Insurance policy end date 2018-02-01 Total amount of commissions paid to insurance broker USD $2,072 Total amount of fees paid to insurance company USD $871 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,072 Amount paid for insurance broker fees 871 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL04461
Policy instance	35
Insurance contract or identification number GVTL04461 Number of Individuals Covered 153 Insurance policy start date 2017-05-01 Insurance policy end date 2018-05-01 Total amount of commissions paid to insurance broker USD $4,533 Total amount of fees paid to insurance company USD $3,735 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,533 Amount paid for insurance broker fees 3735 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	TS05336970
Policy instance	27
Insurance contract or identification number TS05336970 Number of Individuals Covered 2660 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $39,610 Total amount of fees paid to insurance company USD $6,648 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39,610 Amount paid for insurance broker fees 6648 Insurance broker organization code? 3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	17269A
Policy instance	39
Insurance contract or identification number 17269A Number of Individuals Covered 180 Insurance policy start date 2017-02-01 Insurance policy end date 2018-01-31 Total amount of commissions paid to insurance broker USD $65,718 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $65,718 Insurance broker organization code? 3
ANTHEM BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	5
Insurance contract or identification number 275730 Number of Individuals Covered 2089 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $1,182,265 Total amount of fees paid to insurance company USD $77,706 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,182,265 Amount paid for insurance broker fees 77706 Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	9138871
Policy instance	36
Insurance contract or identification number 9138871 Number of Individuals Covered 1157 Insurance policy start date 2017-12-01 Insurance policy end date 2018-12-01 Total amount of commissions paid to insurance broker USD $161,082 Total amount of fees paid to insurance company USD $10,754 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $161,082 Amount paid for insurance broker fees 10754 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12214263
Policy instance	14
Insurance contract or identification number 12214263 Number of Individuals Covered 3637 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $20,689 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,689 Insurance broker organization code? 3 Insurance broker name HEALTH BENEFIT PARTNERS
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 027860
Policy instance	15
Insurance contract or identification number GL 027860 Number of Individuals Covered 245 Insurance policy start date 2016-09-01 Insurance policy end date 2017-08-31 Total amount of commissions paid to insurance broker USD $612 Life Insurance Welfare Benefit Yes Other welfare benefits provided BASIC LIFE Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $612 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	G 162313
Policy instance	16
Insurance contract or identification number G 162313 Number of Individuals Covered 308 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $3,755 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,755 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138673
Policy instance	17
Insurance contract or identification number GL 138673 Number of Individuals Covered 255 Insurance policy start date 2016-04-01 Insurance policy end date 2017-04-01 Total amount of commissions paid to insurance broker USD $3,236 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,236 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138676
Policy instance	18
Insurance contract or identification number GL 138676 Number of Individuals Covered 624 Insurance policy start date 2016-04-01 Insurance policy end date 2017-04-01 Total amount of commissions paid to insurance broker USD $2,715 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,715 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	19
Insurance contract or identification number GL 138677 Number of Individuals Covered 1100 Insurance policy start date 2017-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $35,940 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35,940 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	20
Insurance contract or identification number GL 138680 Number of Individuals Covered 1424 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $1,554 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,554 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 117614
Policy instance	22
Insurance contract or identification number LTD 117614 Number of Individuals Covered 110 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $1,810 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,810 Insurance broker organization code? 3 Insurance broker name
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 123120
Policy instance	23
Insurance contract or identification number LTD 123120 Number of Individuals Covered 27 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $1,367 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,367 Insurance broker organization code? 3 Insurance broker name
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	24
Insurance contract or identification number VAR 203203 Number of Individuals Covered 327 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $2,338 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,338 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12236504
Policy instance	13
Insurance contract or identification number 12236504 Number of Individuals Covered 597 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $2,235 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,235 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3334546
Policy instance	12
Insurance contract or identification number 3334546 Number of Individuals Covered 155 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $9,931 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,931 Insurance broker organization code? 3 Insurance broker name
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277165
Policy instance	1
Insurance contract or identification number 277165 Number of Individuals Covered 314 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $110,793 Are there contracts with allocated funds for individual policies? 1 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $89,004 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	714737
Policy instance	2
Insurance contract or identification number 714737 Number of Individuals Covered 245 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $18,235 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,235 Insurance broker organization code? 3 Insurance broker name INTERCARE INSURANCE SOLUTIONS
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	W0051511,H56182
Policy instance	3
Insurance contract or identification number W0051511,H56182 Number of Individuals Covered 411 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $289,317 Total amount of fees paid to insurance company USD $8,401 Health Insurance Welfare Benefit Yes Other welfare benefits provided DRUG Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $289,317 Amount paid for insurance broker fees 8401 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	276432
Policy instance	4
Insurance contract or identification number 276432 Number of Individuals Covered 120 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $43,657 Total amount of fees paid to insurance company USD $18,264 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,892 Amount paid for insurance broker fees 801 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
ANTHEM BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	5
Insurance contract or identification number 275730 Number of Individuals Covered 2089 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $861,776 Total amount of fees paid to insurance company USD $11,271 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $620,428 Amount paid for insurance broker fees 11271 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL SERVICES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	6
Insurance contract or identification number 227118 Number of Individuals Covered 585 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $182,331 Total amount of fees paid to insurance company USD $4,136 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $182,331 Amount paid for insurance broker fees 4136 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	39723
Policy instance	7
Insurance contract or identification number 39723 Number of Individuals Covered 124 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $29,650 Total amount of fees paid to insurance company USD $434 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,650 Amount paid for insurance broker fees 434 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	114049
Policy instance	8
Insurance contract or identification number 114049 Number of Individuals Covered 1107 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $314,024 Total amount of fees paid to insurance company USD $5,570 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $314,024 Amount paid for insurance broker fees 5570 Insurance broker organization code? 3 Insurance broker name HUB INTERNTIONAL
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL149906
Policy instance	10
Insurance contract or identification number GL149906 Number of Individuals Covered 109 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $1,863 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,863 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	TS05336970
Policy instance	11
Insurance contract or identification number TS05336970 Number of Individuals Covered 2909 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $37,635 Total amount of fees paid to insurance company USD $4,095 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $37,635 Amount paid for insurance broker fees 4095 Insurance broker organization code? 3 Insurance broker name
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10170333
Policy instance	25
Insurance contract or identification number 10170333 Number of Individuals Covered 325 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $2,583 Total amount of fees paid to insurance company USD $963 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,583 Insurance broker organization code? 3 Amount paid for insurance broker fees 963 Insurance broker name HUB INTERNATIONAL INS SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	148655
Policy instance	26
Insurance contract or identification number 148655 Number of Individuals Covered 131 Insurance policy start date 2016-11-01 Insurance policy end date 2017-10-31 Total amount of commissions paid to insurance broker USD $358 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $358 Insurance broker organization code? 3 Insurance broker name ROBERT CARTY INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	148656
Policy instance	27
Insurance contract or identification number 148656 Number of Individuals Covered 131 Insurance policy start date 2016-11-01 Insurance policy end date 2017-10-31 Total amount of commissions paid to insurance broker USD $314 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $314 Insurance broker organization code? 3 Insurance broker name ROBERT CARTY INSURANCE SERVICES
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10148657
Policy instance	38
Insurance contract or identification number 10148657 Number of Individuals Covered 131 Insurance policy start date 2016-11-01 Insurance policy end date 2017-10-31 Total amount of commissions paid to insurance broker USD $67 Other welfare benefits provided WEEKLY INCOME Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $67 Insurance broker organization code? 3 Insurance broker name
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10170334
Policy instance	39
Insurance contract or identification number 10170334 Number of Individuals Covered 22 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $8,082 Total amount of fees paid to insurance company USD $1,615 Other welfare benefits provided WEEKLY INCOME Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,082 Insurance broker organization code? 3 Amount paid for insurance broker fees 1615 Insurance broker name HUB INTERNATIONAL INS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000
Policy instance	40
Insurance contract or identification number 400001000 Number of Individuals Covered 96 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $1,490 Total amount of fees paid to insurance company USD $570 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,490 Insurance broker organization code? 3 Amount paid for insurance broker fees 570 Insurance broker name HUB INTERNATIONAL INSURANCE
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	902131
Policy instance	41
Insurance contract or identification number 902131 Number of Individuals Covered 160 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $54,724 Total amount of fees paid to insurance company USD $5,909 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $54,724 Insurance broker organization code? 3 Amount paid for insurance broker fees 5909 Insurance broker name INTERCARE INS SOLUTIONS INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0ARZN
Policy instance	42
Insurance contract or identification number GLUG0ARZN Number of Individuals Covered 78 Insurance policy start date 2016-01-01 Insurance policy end date 2017-01-01 Total amount of commissions paid to insurance broker USD $1,167 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $990 Insurance broker organization code? 3 Insurance broker name HEATH BENEFIT PARTNERS INS SOLUTION
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TS05336970
Policy instance	43
Insurance contract or identification number TS05336970 Number of Individuals Covered 2046 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $195,535 Total amount of fees paid to insurance company USD $21,212 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $195,535 Amount paid for insurance broker fees 21212 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTLOARZN
Policy instance	44
Insurance contract or identification number GVTLOARZN Number of Individuals Covered 78 Insurance policy start date 2016-01-01 Insurance policy end date 2017-01-01 Total amount of commissions paid to insurance broker USD $1,167 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $990 Insurance broker organization code? 3 Insurance broker name HEALTH BENEFITS PARTNERS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000ARZN
Policy instance	45
Insurance contract or identification number G000ARZN Number of Individuals Covered 346 Insurance policy end date 2017-01-01 Total amount of commissions paid to insurance broker USD $312 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $256 Insurance broker organization code? 3 Insurance broker name HEALTH BENEFITS PARTNERS INS
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	77033A
Policy instance	46
Insurance contract or identification number 77033A Number of Individuals Covered 183 Insurance policy start date 2016-03-01 Insurance policy end date 2017-02-28 Total amount of commissions paid to insurance broker USD $45,730 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $45,730 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERV
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	17269A
Policy instance	47
Insurance contract or identification number 17269A Number of Individuals Covered 169 Insurance policy start date 2016-02-01 Insurance policy end date 2017-01-31 Total amount of commissions paid to insurance broker USD $49,523 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $49,523 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	LB006B, LB006A
Policy instance	37
Insurance contract or identification number LB006B, LB006A Number of Individuals Covered 111 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $24,673 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,673 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	010-041014
Policy instance	36
Insurance contract or identification number 010-041014 Number of Individuals Covered 152 Insurance policy start date 2016-08-01 Insurance policy end date 2017-07-31 Total amount of commissions paid to insurance broker USD $3,126 Total amount of fees paid to insurance company USD $3,401 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 3401 Insurance broker organization code? 3 Commission paid to Insurance Broker USD $3,126 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7545759
Policy instance	28
Insurance contract or identification number E7545759 Number of Individuals Covered 1 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $36 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21 Insurance broker organization code? 3 Insurance broker name LEOBARDO PINEDA
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	76727
Policy instance	29
Insurance contract or identification number 76727 Number of Individuals Covered 191 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $2,022 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,022 Insurance broker organization code? 3 Insurance broker name SEQUOA BENEFITS & INSURANCE
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	16030
Policy instance	30
Insurance contract or identification number 16030 Number of Individuals Covered 853 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $62,554 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $62,554 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	31
Insurance contract or identification number G000702H Number of Individuals Covered 62 Insurance policy start date 2016-02-01 Insurance policy end date 2017-02-01 Total amount of commissions paid to insurance broker USD $2,143 Total amount of fees paid to insurance company USD $62 Other welfare benefits provided PREFERRED CHOICE VOLUNTARY STD Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,607 Amount paid for insurance broker fees 62 Insurance broker organization code? 3 Insurance broker name EDWARD BRADBURY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	32
Insurance contract or identification number G000702H Number of Individuals Covered 317 Insurance policy start date 2016-02-01 Insurance policy end date 2017-02-01 Total amount of commissions paid to insurance broker USD $1,034 Total amount of fees paid to insurance company USD $483 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,034 Amount paid for insurance broker fees 483 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0702H
Policy instance	33
Insurance contract or identification number GLUG0702H Number of Individuals Covered 64 Insurance policy start date 2016-02-01 Insurance policy end date 2017-02-01 Total amount of commissions paid to insurance broker USD $1,926 Total amount of fees paid to insurance company USD $797 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,926 Amount paid for insurance broker fees 797 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	21
Insurance contract or identification number LTD 112593 Number of Individuals Covered 1068 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $7,108 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,108 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL04461
Policy instance	34
Insurance contract or identification number GVTL04461 Number of Individuals Covered 573 Insurance policy start date 2016-05-01 Insurance policy end date 2017-05-01 Total amount of commissions paid to insurance broker USD $1,454 Total amount of fees paid to insurance company USD $708 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,454 Amount paid for insurance broker fees 708 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	35
Insurance contract or identification number G0004461 Number of Individuals Covered 138 Insurance policy start date 2016-05-01 Insurance policy end date 2017-05-01 Total amount of commissions paid to insurance broker USD $5,575 Total amount of fees paid to insurance company USD $2,670 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,575 Amount paid for insurance broker fees 2670 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	600306
Policy instance	9
Insurance contract or identification number 600306 Number of Individuals Covered 640 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $251,390 Total amount of fees paid to insurance company USD $4,515 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $251,390 Amount paid for insurance broker fees 4515 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	76724
Policy instance	30
Insurance contract or identification number 76724 Number of Individuals Covered 643 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $10,792 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,792 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12214263
Policy instance	45
Insurance contract or identification number 12214263 Number of Individuals Covered 2818 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $18,633 Total amount of fees paid to insurance company USD $24 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,633 Amount paid for insurance broker fees 24 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	32
Insurance contract or identification number G000702H Number of Individuals Covered 41 Insurance policy start date 2014-02-01 Insurance policy end date 2015-02-01 Total amount of commissions paid to insurance broker USD $1,668 Total amount of fees paid to insurance company USD $474 Other welfare benefits provided PREFERRED CHOICE VOLUNTARY STD Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,251 Amount paid for insurance broker fees 412 Insurance broker organization code? 3 Insurance broker name
ANTHEM BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	5
Insurance contract or identification number 275730 Number of Individuals Covered 2674 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $850,167 Total amount of fees paid to insurance company USD $5,910 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $850,167 Amount paid for insurance broker fees 5910 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL SERVICES
AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )
Policy contract number	11001-1536
Policy instance	31
Insurance contract or identification number 11001-1536 Number of Individuals Covered 89 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $689 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $689 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	16030
Policy instance	29
Insurance contract or identification number 16030 Number of Individuals Covered 928 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $65,110 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $65,110 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7545759
Policy instance	28
Insurance contract or identification number E7545759 Number of Individuals Covered 1 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $74 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32 Insurance broker organization code? 3 Insurance broker name REYNALDO GRAJEDA
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	148656
Policy instance	27
Insurance contract or identification number 148656 Number of Individuals Covered 102 Insurance policy start date 2014-11-01 Insurance policy end date 2015-10-31 Total amount of commissions paid to insurance broker USD $1,604 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,604 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONL INSURANCE COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	148655
Policy instance	26
Insurance contract or identification number 148655 Number of Individuals Covered 102 Insurance policy start date 2014-11-01 Insurance policy end date 2015-10-31 Total amount of commissions paid to insurance broker USD $1,682 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,682 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10170333
Policy instance	25
Insurance contract or identification number 10170333 Number of Individuals Covered 1 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-30 Total amount of commissions paid to insurance broker USD $3,324 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,324 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	24
Insurance contract or identification number VAR 203203 Number of Individuals Covered 317 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $3,004 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,004 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 123120
Policy instance	23
Insurance contract or identification number LTD 123120 Number of Individuals Covered 78 Insurance policy start date 2014-04-01 Insurance policy end date 2015-04-01 Total amount of commissions paid to insurance broker USD $3,327 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,327 Insurance broker organization code? 3 Insurance broker name
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	33
Insurance contract or identification number G000702H Number of Individuals Covered 277 Insurance policy start date 2014-02-01 Insurance policy end date 2015-02-01 Total amount of commissions paid to insurance broker USD $1,108 Total amount of fees paid to insurance company USD $579 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,108 Amount paid for insurance broker fees 579 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0702H
Policy instance	34
Insurance contract or identification number GLUG0702H Number of Individuals Covered 64 Insurance policy start date 2014-02-01 Insurance policy end date 2015-02-01 Total amount of commissions paid to insurance broker USD $1,860 Total amount of fees paid to insurance company USD $1,152 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,860 Amount paid for insurance broker fees 1152 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	902131
Policy instance	44
Insurance contract or identification number 902131 Number of Individuals Covered 146 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $42,833 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $42,833 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000
Policy instance	43
Insurance contract or identification number 400001000 Number of Individuals Covered 113 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-30 Total amount of commissions paid to insurance broker USD $1,940 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,940 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10170334
Policy instance	42
Insurance contract or identification number 10170334 Number of Individuals Covered 52 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-30 Total amount of commissions paid to insurance broker USD $5,602 Other welfare benefits provided WEEKLY INCOME Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,602 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10148657
Policy instance	41
Insurance contract or identification number 10148657 Number of Individuals Covered 102 Insurance policy start date 2014-11-01 Insurance policy end date 2015-10-31 Total amount of commissions paid to insurance broker USD $354 Other welfare benefits provided WEEKLY INCOME Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $354 Insurance broker organization code? 3 Insurance broker name
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	LB006B, LB006A
Policy instance	40
Insurance contract or identification number LB006B, LB006A Number of Individuals Covered 139 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $7,724 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,724 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	276432
Policy instance	39
Insurance contract or identification number 276432 Number of Individuals Covered 131 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $41,937 Total amount of fees paid to insurance company USD $460 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $41,937 Amount paid for insurance broker fees 460 Insurance broker organization code? 3 Insurance broker name HUB INTERNTIONAL INSURANCE SERVICES
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number	010-041014
Policy instance	38
Insurance contract or identification number 010-041014 Number of Individuals Covered 490 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $9,754 Total amount of fees paid to insurance company USD $3,757 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,754 Insurance broker organization code? 3 Amount paid for insurance broker fees 3757 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	0806270HNO
Policy instance	37
Insurance contract or identification number 0806270HNO Number of Individuals Covered 176 Insurance policy start date 2014-02-01 Insurance policy end date 2015-01-31 Total amount of commissions paid to insurance broker USD $44,295 Welfare Benefit Premiums Paid to Carrier USD $772,536 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $44,295 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	36
Insurance contract or identification number G0004461 Number of Individuals Covered 606 Insurance policy start date 2014-05-01 Insurance policy end date 2015-05-01 Total amount of commissions paid to insurance broker USD $1,665 Total amount of fees paid to insurance company USD $929 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,665 Amount paid for insurance broker fees 929 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL04461
Policy instance	35
Insurance contract or identification number GVTL04461 Number of Individuals Covered 171 Insurance policy start date 2014-05-01 Insurance policy end date 2015-05-01 Total amount of commissions paid to insurance broker USD $6,577 Total amount of fees paid to insurance company USD $3,559 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,577 Amount paid for insurance broker fees 3559 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 117614
Policy instance	22
Insurance contract or identification number LTD 117614 Number of Individuals Covered 58 Insurance policy start date 2014-04-01 Insurance policy end date 2015-04-01 Total amount of commissions paid to insurance broker USD $1,324 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,324 Insurance broker organization code? 3 Insurance broker name
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	21
Insurance contract or identification number LTD 112593 Number of Individuals Covered 1100 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $8,609 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,609 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	20
Insurance contract or identification number GL 138680 Number of Individuals Covered 831 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $3,500 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,500 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	94-1340523
Policy instance	8
Insurance contract or identification number 94-1340523 Number of Individuals Covered 975 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-30 Total amount of commissions paid to insurance broker USD $500,774 Total amount of fees paid to insurance company USD $3,118 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $500,774 Amount paid for insurance broker fees 3118 Insurance broker organization code? 3 Insurance broker name HUB INTERNTIONAL
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	39723
Policy instance	7
Insurance contract or identification number 39723 Number of Individuals Covered 67 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-30 Total amount of commissions paid to insurance broker USD $29,784 Total amount of fees paid to insurance company USD $252 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,784 Amount paid for insurance broker fees 252 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	6
Insurance contract or identification number 227118 Number of Individuals Covered 549 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-30 Total amount of commissions paid to insurance broker USD $166,182 Total amount of fees paid to insurance company USD $1,924 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $166,182 Amount paid for insurance broker fees 1924 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	19
Insurance contract or identification number GL 138677 Number of Individuals Covered 903 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $37,433 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $37,433 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277165
Policy instance	4
Insurance contract or identification number 277165 Number of Individuals Covered 269 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $119,076 Total amount of fees paid to insurance company USD $1,025 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $119,076 Amount paid for insurance broker fees 1025 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0806270
Policy instance	3
Insurance contract or identification number 0806270 Number of Individuals Covered 30 Insurance policy start date 2014-02-01 Insurance policy end date 2015-01-31 Total amount of commissions paid to insurance broker USD $10,713 Total amount of fees paid to insurance company USD $8,589 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,713 Amount paid for insurance broker fees 8589 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	714737
Policy instance	2
Insurance contract or identification number 714737 Number of Individuals Covered 330 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $-24 Total amount of fees paid to insurance company USD $101,173 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $-24 Amount paid for insurance broker fees 101173 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	ZH5888, 944762,
Policy instance	1
Insurance contract or identification number ZH5888, 944762, Number of Individuals Covered 500 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $330,067 Total amount of fees paid to insurance company USD $141 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $330,067 Amount paid for insurance broker fees 141 Insurance broker organization code? 3 Insurance broker name
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	600306
Policy instance	9
Insurance contract or identification number 600306 Number of Individuals Covered 649 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-01 Total amount of commissions paid to insurance broker USD $283,106 Total amount of fees paid to insurance company USD $2,568 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $283,106 Amount paid for insurance broker fees 2568 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	13-5581829
Policy instance	10
Insurance contract or identification number 13-5581829 Number of Individuals Covered 1842 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $164,996 Total amount of fees paid to insurance company USD $28,018 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $164,996 Amount paid for insurance broker fees 28018 Insurance broker organization code? 3 Insurance broker name
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	TS05336970
Policy instance	11
Insurance contract or identification number TS05336970 Number of Individuals Covered 2350 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $28,875 Total amount of fees paid to insurance company USD $4,823 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,875 Amount paid for insurance broker fees 4823 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138676
Policy instance	18
Insurance contract or identification number GL 138676 Number of Individuals Covered 681 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $2,370 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,370 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138673
Policy instance	17
Insurance contract or identification number GL 138673 Number of Individuals Covered 353 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $2,692 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,692 Insurance broker name HUB INTERNATIONAL
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	G 162313
Policy instance	16
Insurance contract or identification number G 162313 Number of Individuals Covered 231 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $3,485 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,485 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 027860
Policy instance	15
Insurance contract or identification number GL 027860 Number of Individuals Covered 264 Insurance policy start date 2014-04-01 Insurance policy end date 2015-04-01 Total amount of commissions paid to insurance broker USD $667 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $667 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30019646
Policy instance	14
Insurance contract or identification number 30019646 Number of Individuals Covered 197 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $1,560 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,560 Insurance broker organization code? 3 Insurance broker name DUBLIN INSURANCE SERVICES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12236504
Policy instance	13
Insurance contract or identification number 12236504 Number of Individuals Covered 518 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $2,379 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,379 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3334546
Policy instance	12
Insurance contract or identification number 3334546 Number of Individuals Covered 133 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $7,337 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,337 Insurance broker organization code? 3 Insurance broker name
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3334546
Policy instance	13
Insurance contract or identification number 3334546 Number of Individuals Covered 118 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $8,249 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,249 Insurance broker organization code? 3 Insurance broker name
SECURECARE DENTAL (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number	90-1025553
Policy instance	14
Insurance contract or identification number 90-1025553 Number of Individuals Covered 14 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $98 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $98 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number	10006028
Policy instance	15
Insurance contract or identification number 10006028 Number of Individuals Covered 84 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $1,988 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,988 Insurance broker name HUB INTERNATIONAL'
AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number	100006030
Policy instance	16
Insurance contract or identification number 100006030 Number of Individuals Covered 33 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $881 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $881 Insurance broker organization code? 3 Insurance broker name
AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number	10006031
Policy instance	17
Insurance contract or identification number 10006031 Number of Individuals Covered 21 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $485 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $485 Insurance broker organization code? 3 Insurance broker name
AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number	10006029
Policy instance	18
Insurance contract or identification number 10006029 Number of Individuals Covered 96 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $1,998 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,998 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12236504
Policy instance	19
Insurance contract or identification number 12236504 Number of Individuals Covered 708 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $2,509 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,509 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30019646
Policy instance	20
Insurance contract or identification number 30019646 Number of Individuals Covered 221 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $1,680 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,680 Insurance broker organization code? 3 Insurance broker name DUBLIN INSURANCE SERVICES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 027860
Policy instance	21
Insurance contract or identification number GL 027860 Number of Individuals Covered 562 Insurance policy start date 2013-02-01 Insurance policy end date 2014-01-01 Total amount of commissions paid to insurance broker USD $895 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $895 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	G 162313
Policy instance	22
Insurance contract or identification number G 162313 Number of Individuals Covered 19 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $3,236 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,236 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	TS05336970
Policy instance	12
Insurance contract or identification number TS05336970 Number of Individuals Covered 2270 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $27,329 Total amount of fees paid to insurance company USD $1,366 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $27,329 Amount paid for insurance broker fees 1366 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	13-5581829
Policy instance	11
Insurance contract or identification number 13-5581829 Number of Individuals Covered 2697 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $144,808 Total amount of fees paid to insurance company USD $7,240 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $144,808 Amount paid for insurance broker fees 7240 Insurance broker organization code? 3 Insurance broker name
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	94-1340523
Policy instance	10
Insurance contract or identification number 94-1340523 Number of Individuals Covered 622 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-30 Total amount of commissions paid to insurance broker USD $170,907 Total amount of fees paid to insurance company USD $262 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $170,907 Amount paid for insurance broker fees 262 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	ZH5888, 944762,
Policy instance	1
Insurance contract or identification number ZH5888, 944762, Number of Individuals Covered 1088 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $356,014 Total amount of fees paid to insurance company USD $4,076 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $356,014 Amount paid for insurance broker fees 4076 Insurance broker organization code? 3 Insurance broker name
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00607709
Policy instance	2
Insurance contract or identification number 00607709 Number of Individuals Covered 124 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $35,095 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35,095 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	714737
Policy instance	3
Insurance contract or identification number 714737 Number of Individuals Covered 330 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $4,929 Total amount of fees paid to insurance company USD $93,458 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,755,049 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,908 Amount paid for insurance broker fees 93458 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0806270
Policy instance	4
Insurance contract or identification number 0806270 Number of Individuals Covered 31 Insurance policy start date 2013-02-01 Insurance policy end date 2014-01-31 Total amount of commissions paid to insurance broker USD $10,440 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,440 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	277165
Policy instance	5
Insurance contract or identification number 277165 Number of Individuals Covered 580 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $104,196 Total amount of fees paid to insurance company USD $162 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,698,979 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $104,196 Amount paid for insurance broker fees 162 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
ANTHEM BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	6
Insurance contract or identification number 275730 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	941340523
Policy instance	7
Insurance contract or identification number 941340523 Number of Individuals Covered 1020 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-30 Total amount of commissions paid to insurance broker USD $107,509 Total amount of fees paid to insurance company USD $241 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $107,509 Amount paid for insurance broker fees 241 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	39723
Policy instance	8
Insurance contract or identification number 39723 Number of Individuals Covered 98 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-01 Total amount of commissions paid to insurance broker USD $29,829 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,829 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	94-1340523
Policy instance	9
Insurance contract or identification number 94-1340523 Number of Individuals Covered 886 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $361,070 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $361,070 Insurance broker organization code? 3 Insurance broker name HUB INTERNTIONAL
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10170334
Policy instance	33
Insurance contract or identification number 10170334 Number of Individuals Covered 52 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $5,235 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,235 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONL INSURANCE COMPANY
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138673
Policy instance	23
Insurance contract or identification number GL 138673 Number of Individuals Covered 246 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $2,255 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,255 Insurance broker name HUB INTERNATIONAL
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	76724
Policy instance	36
Insurance contract or identification number 76724 Number of Individuals Covered 919 Insurance policy start date 2013-09-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $8,805 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,805 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )
Policy contract number	11001-1537
Policy instance	37
Insurance contract or identification number 11001-1537 Number of Individuals Covered 25 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $215 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $215 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )
Policy contract number	11001-1538
Policy instance	38
Insurance contract or identification number 11001-1538 Number of Individuals Covered 38 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of fees paid to insurance company USD $310 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 310 Insurance broker organization code? 3 Insurance broker name HUB INTERNTIONAL
AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )
Policy contract number	11001-1536
Policy instance	39
Insurance contract or identification number 11001-1536 Number of Individuals Covered 89 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $731 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $731 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	46
Insurance contract or identification number G000702H Number of Individuals Covered 61 Insurance policy start date 2013-02-01 Insurance policy end date 2014-02-01 Total amount of commissions paid to insurance broker USD $2,008 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,506 Insurance broker organization code? 3 Insurance broker name THOMAS EDWARD BRADBURY
AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )
Policy contract number	11001-1539
Policy instance	40
Insurance contract or identification number 11001-1539 Number of Individuals Covered 69 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $616 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $616 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138673
Policy instance	41
Insurance contract or identification number GL 138673 Number of Individuals Covered 246 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $2,255 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,255 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0702H
Policy instance	45
Insurance contract or identification number GLUG0702H Number of Individuals Covered 264 Insurance policy start date 2013-02-01 Insurance policy end date 2014-02-01 Total amount of commissions paid to insurance broker USD $1,071 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,071 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0702H
Policy instance	47
Insurance contract or identification number GVTL0702H Number of Individuals Covered 87 Insurance policy start date 2013-02-01 Insurance policy end date 2014-02-01 Total amount of commissions paid to insurance broker USD $2,104 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,104 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R03633812
Policy instance	42
Insurance contract or identification number R03633812 Number of Individuals Covered 715 Insurance policy start date 2013-12-01 Insurance policy end date 2014-12-01 Total amount of commissions paid to insurance broker USD $63,491 Total amount of fees paid to insurance company USD $3,141 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $63,491 Amount paid for insurance broker fees 3141 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	16030
Policy instance	35
Insurance contract or identification number 16030 Number of Individuals Covered 1130 Insurance policy start date 2013-09-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $43,697 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $43,697 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7545759
Policy instance	34
Insurance contract or identification number E7545759 Number of Individuals Covered 4 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $328 Total amount of fees paid to insurance company USD $14 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $73 Insurance broker organization code? 3 Amount paid for insurance broker fees 7 Insurance broker name REYNALDO GRAJEDA
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138676
Policy instance	24
Insurance contract or identification number GL 138676 Number of Individuals Covered 124 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $2,152 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,152 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	25
Insurance contract or identification number GL 138677 Number of Individuals Covered 999 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $36,147 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $36,147 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	26
Insurance contract or identification number GL 138680 Number of Individuals Covered 897 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $3,132 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,132 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	27
Insurance contract or identification number LTD 112593 Number of Individuals Covered 1136 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $8,016 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,016 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 117614
Policy instance	28
Insurance contract or identification number LTD 117614 Number of Individuals Covered 62 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $1,011 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,011 Insurance broker organization code? 3 Insurance broker name
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 123120
Policy instance	29
Insurance contract or identification number LTD 123120 Number of Individuals Covered 26 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $1,627 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,627 Insurance broker organization code? 3 Insurance broker name
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	30
Insurance contract or identification number VAR 203203 Number of Individuals Covered 297 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $2,988 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,988 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10170333
Policy instance	31
Insurance contract or identification number 10170333 Number of Individuals Covered 429 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $2,820 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,820 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10170333
Policy instance	32
Insurance contract or identification number 10170333 Number of Individuals Covered 159 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $2,613 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,613 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	44
Insurance contract or identification number G0004461 Number of Individuals Covered 217 Insurance policy start date 2013-05-01 Insurance policy end date 2014-05-01 Total amount of commissions paid to insurance broker USD $7,865 Total amount of fees paid to insurance company USD $4,557 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,865 Amount paid for insurance broker fees 4557 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG04461
Policy instance	43
Insurance contract or identification number GLUG04461 Number of Individuals Covered 816 Insurance policy start date 2013-05-01 Insurance policy end date 2014-05-01 Total amount of commissions paid to insurance broker USD $1,973 Total amount of fees paid to insurance company USD $1,078 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,973 Amount paid for insurance broker fees 1078 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	0714737
Policy instance	44
Insurance contract or identification number 0714737 Number of Individuals Covered 33 Insurance policy start date 2012-05-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $82,441 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,744 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	23
Insurance contract or identification number LTD 112593 Number of Individuals Covered 1454 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $8,783 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,783 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERV
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 117614
Policy instance	22
Insurance contract or identification number LTD 117614 Number of Individuals Covered 140 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $1,177 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,177 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS SERVICES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	21
Insurance contract or identification number GL 138677 Number of Individuals Covered 999 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $33,673 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,673 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138676
Policy instance	20
Insurance contract or identification number GL 138676 Number of Individuals Covered 98 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $865 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $865 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138673
Policy instance	19
Insurance contract or identification number GL 138673 Number of Individuals Covered 199 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $1,622 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,622 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS SERV
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 027860
Policy instance	18
Insurance contract or identification number GL 027860 Number of Individuals Covered 562 Insurance policy start date 2012-02-01 Insurance policy end date 2013-01-31 Total amount of commissions paid to insurance broker USD $1,617 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,617 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	114049
Policy instance	16
Insurance contract or identification number 114049 Number of Individuals Covered 928 Insurance policy start date 2012-01-01 Insurance policy end date 2013-03-01 Total amount of commissions paid to insurance broker USD $238,580 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $238,580 Insurance broker organization code? 3 Insurance broker name HUB INTERNALTIONAL
KAISER FOUNDATION HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	39723
Policy instance	15
Insurance contract or identification number 39723 Number of Individuals Covered 93 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-01 Total amount of commissions paid to insurance broker USD $29,527 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,527 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	600306
Policy instance	14
Insurance contract or identification number 600306 Number of Individuals Covered 855 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-01 Total amount of commissions paid to insurance broker USD $313,716 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $132,582 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS SERV
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	13
Insurance contract or identification number 227118 Number of Individuals Covered 627 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-01 Total amount of commissions paid to insurance broker USD $153,529 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $153,529 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL & ASSOC
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	277165
Policy instance	12
Insurance contract or identification number 277165 Number of Individuals Covered 551 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $89,325 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $89,325 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	11
Insurance contract or identification number G0004461 Number of Individuals Covered 1130 Insurance policy start date 2012-05-01 Insurance policy end date 2013-05-01 Total amount of commissions paid to insurance broker USD $1,991 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,173 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS SERV
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	10
Insurance contract or identification number G000702H Number of Individuals Covered 267 Insurance policy start date 2012-02-01 Insurance policy end date 2013-02-01 Total amount of commissions paid to insurance broker USD $989 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $815 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS SER
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	0170333
Policy instance	9
Insurance contract or identification number 0170333 Number of Individuals Covered 363 Insurance policy start date 2012-12-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $1,517 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $874 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERV
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	8
Insurance contract or identification number G000702H Number of Individuals Covered 96 Insurance policy start date 2012-02-01 Insurance policy end date 2013-02-01 Total amount of commissions paid to insurance broker USD $2,551 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,152 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS SERV
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	TWS05336970
Policy instance	6
Insurance contract or identification number TWS05336970 Number of Individuals Covered 2305 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $24,380 Total amount of fees paid to insurance company USD $457 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,244 Insurance broker organization code? 3 Amount paid for insurance broker fees 457 Insurance broker name HUB INTERNATIONAL INS SERV
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 123120
Policy instance	24
Insurance contract or identification number LTD 123120 Number of Individuals Covered 8 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $610 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $610 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	25
Insurance contract or identification number VAR 203203 Number of Individuals Covered 292 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $2,797 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,797 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	16391
Policy instance	43
Insurance contract or identification number 16391 Number of Individuals Covered 145 Insurance policy start date 2012-12-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $1,499 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $875 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS SERV
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10170334
Policy instance	42
Insurance contract or identification number 10170334 Number of Individuals Covered 51 Insurance policy start date 2012-12-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $4,126 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,349 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS SERV
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00607709
Policy instance	41
Insurance contract or identification number 00607709 Number of Individuals Covered 138 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $36,070 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $36,070 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00607709
Policy instance	40
Insurance contract or identification number 00607709 Number of Individuals Covered 146 Insurance policy end date 2013-01-31 Total amount of commissions paid to insurance broker USD $30,600 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,600 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCN & ASSOCIATES
AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )
Policy contract number	11001-1536
Policy instance	39
Insurance contract or identification number 11001-1536 Number of Individuals Covered 83 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $351 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $179 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA
AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )
Policy contract number	11001-1539
Policy instance	38
Insurance contract or identification number 11001-1539 Number of Individuals Covered 77 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $329 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $190 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA
AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )
Policy contract number	11001-1538
Policy instance	37
Insurance contract or identification number 11001-1538 Number of Individuals Covered 32 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $190 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $108 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	76724
Policy instance	34
Insurance contract or identification number 76724 Number of Individuals Covered 1075 Insurance policy start date 2012-09-01 Insurance policy end date 2013-08-31 Total amount of fees paid to insurance company USD $15,006 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 15006 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	16030
Policy instance	35
Insurance contract or identification number 16030 Number of Individuals Covered 906 Insurance policy start date 2012-09-01 Insurance policy end date 2013-08-31 Total amount of commissions paid to insurance broker USD $45,375 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $45,375 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERV
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	10006029
Policy instance	33
Insurance contract or identification number 10006029 Number of Individuals Covered 80 Insurance policy end date 2013-07-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Insurance broker organization code? 1 Insurance broker name WILLIS OF ARIZONA INC
AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number	10006029
Policy instance	32
Insurance contract or identification number 10006029 Number of Individuals Covered 80 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $734 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $585 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA INC
AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number	10006030
Policy instance	31
Insurance contract or identification number 10006030 Number of Individuals Covered 39 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $333 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $258 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA INC
AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number	10006031
Policy instance	29
Insurance contract or identification number 10006031 Number of Individuals Covered 12 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $120 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $90 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA INC
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	3334546
Policy instance	27
Insurance contract or identification number 3334546 Number of Individuals Covered 139 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $6,720 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,720 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	806270
Policy instance	28
Insurance contract or identification number 806270 Number of Individuals Covered 30 Insurance policy start date 2012-02-01 Insurance policy end date 2013-01-31 Total amount of commissions paid to insurance broker USD $22,907 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,922 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	26
Insurance contract or identification number GL 138680 Number of Individuals Covered 1047 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $3,604 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,604 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERV
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0702H
Policy instance	7
Insurance contract or identification number GVTL0702H Number of Individuals Covered 68 Insurance policy start date 2012-02-01 Insurance policy end date 2013-02-01 Total amount of commissions paid to insurance broker USD $1,808 Other welfare benefits provided PREFERRED CHOICE VOLUNTARY STD Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Life Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $1,433 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS SERV
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TS05336970
Policy instance	5
Insurance contract or identification number TS05336970 Number of Individuals Covered 2449 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $127,402 Total amount of fees paid to insurance company USD $2,383 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $79,747 Insurance broker organization code? 3 Amount paid for insurance broker fees 2383 Insurance broker name HUB INTERNATIONAL INS SERV
AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )
Policy contract number	11001-1537
Policy instance	36
Insurance contract or identification number 11001-1537 Number of Individuals Covered 18 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $98 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $60 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA
AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number	10006028
Policy instance	30
Insurance contract or identification number 10006028 Number of Individuals Covered 54 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $656 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $513 Insurance broker organization code? 3 Insurance broker name WILLIS OF ARIZONA INC
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	17
Insurance contract or identification number 275730 Number of Individuals Covered 2880 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $647,115 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $647,115 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERV
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	2023358
Policy instance	1
Insurance contract or identification number 2023358 Number of Individuals Covered 1239 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $341,334 Total amount of fees paid to insurance company USD $2,872 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $116,914 Amount paid for insurance broker fees 2872 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30019646
Policy instance	2
Insurance contract or identification number 30019646 Number of Individuals Covered 243 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $1,592 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,592 Insurance broker organization code? 3 Insurance broker name DUBLIN INSURANCE SERVICES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12214263
Policy instance	3
Insurance contract or identification number 12214263 Number of Individuals Covered 2195 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $14,847 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,658 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12236504
Policy instance	4
Insurance contract or identification number 12236504 Number of Individuals Covered 704 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $1,477 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,477 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN ASSOCIATES
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number
Policy instance	14
Number of Individuals Covered 185 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $84,246 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $84,246 Insurance broker organization code? 3 Insurance broker name
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number	5396464
Policy instance	13
Insurance contract or identification number 5396464 Number of Individuals Covered 125 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $2,676 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,676 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5396464
Policy instance	12
Insurance contract or identification number 5396464 Number of Individuals Covered 76 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $9,321 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,321 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	11
Insurance contract or identification number G0004461 Number of Individuals Covered 2122 Insurance policy start date 2011-05-01 Insurance policy end date 2012-05-01 Total amount of commissions paid to insurance broker USD $2,122 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,122 Insurance broker organization code? 3 Insurance broker name
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275702
Policy instance	9
Insurance contract or identification number 275702 Number of Individuals Covered 172 Insurance policy start date 2011-02-01 Insurance policy end date 2012-01-31 Total amount of commissions paid to insurance broker USD $24,747 Total amount of fees paid to insurance company USD $4,949 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,747 Insurance broker organization code? 3 Amount paid for insurance broker fees 4949 Insurance broker name LISH INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	10
Insurance contract or identification number G0004461 Number of Individuals Covered 281 Insurance policy start date 2011-05-01 Insurance policy end date 2012-05-01 Total amount of commissions paid to insurance broker USD $7,376 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,376 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	470322111
Policy instance	8
Insurance contract or identification number 470322111 Number of Individuals Covered 231 Insurance policy start date 2011-02-01 Insurance policy end date 2012-02-01 Total amount of commissions paid to insurance broker USD $896 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $896 Insurance broker organization code? 3 Insurance broker name SIDLES AND DUNCAN ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0702H
Policy instance	7
Insurance contract or identification number GVTL0702H Number of Individuals Covered 47 Insurance policy start date 2011-02-01 Insurance policy end date 2012-02-01 Total amount of commissions paid to insurance broker USD $1,277 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,277 Insurance broker organization code? 3 Insurance broker name SIDLES AND DUNCAN ASSOCIATES
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	TWS05336970
Policy instance	6
Insurance contract or identification number TWS05336970 Number of Individuals Covered 1938 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $25,392 Total amount of fees paid to insurance company USD $4,670 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,392 Amount paid for insurance broker fees 4670 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TS05336970
Policy instance	5
Insurance contract or identification number TS05336970 Number of Individuals Covered 1950 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $128,729 Total amount of fees paid to insurance company USD $23,648 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $128,729 Amount paid for insurance broker fees 23648 Insurance broker organization code? 3 Insurance broker name
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12246504
Policy instance	4
Insurance contract or identification number 12246504 Number of Individuals Covered 756 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $2,493 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Vision Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $2,493 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN ASSOCIATES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12214263
Policy instance	3
Insurance contract or identification number 12214263 Number of Individuals Covered 2225 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $14,458 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Vision Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $14,458 Insurance broker organization code? 3 Insurance broker name SHEILA HARTMAN
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30019646
Policy instance	2
Insurance contract or identification number 30019646 Number of Individuals Covered 233 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $1,514 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,514 Insurance broker organization code? 3 Insurance broker name DUBLIN INSURANCE SERVICES
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number
Policy instance	16
Number of Individuals Covered 2565 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $80,436 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $80,436 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number
Policy instance	15
Number of Individuals Covered 99 Insurance policy start date 2011-02-01 Insurance policy end date 2012-01-31 Total amount of commissions paid to insurance broker USD $18,060 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Health Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $18,060 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	31
Insurance contract or identification number GL 138680 Number of Individuals Covered 1051 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $5,934 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,934 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 117614
Policy instance	29
Insurance contract or identification number LTD 117614 Number of Individuals Covered 140 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $3,114 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,114 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	28
Insurance contract or identification number LTD 112593 Number of Individuals Covered 1460 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $12,331 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,331 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 117614
Policy instance	27
Insurance contract or identification number LTD 117614 Number of Individuals Covered 127 Insurance policy start date 2011-02-01 Insurance policy end date 2012-01-31 Total amount of commissions paid to insurance broker USD $3,102 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,102 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	26
Insurance contract or identification number GL 138677 Number of Individuals Covered 911 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $29,530 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,530 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	30
Insurance contract or identification number VAR 203203 Number of Individuals Covered 260 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $2,598 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,598 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138676
Policy instance	25
Insurance contract or identification number GL 138676 Number of Individuals Covered 92 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $1,560 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Life Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $1,560 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138673
Policy instance	24
Insurance contract or identification number GL 138673 Number of Individuals Covered 195 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $2,554 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,554 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 027860
Policy instance	23
Insurance contract or identification number GL 027860 Number of Individuals Covered 562 Insurance policy start date 2011-04-01 Insurance policy end date 2012-01-31 Total amount of commissions paid to insurance broker USD $1,336 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,336 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INSURANCE SERVICE
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	22
Insurance contract or identification number 275730 Number of Individuals Covered 3048 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $642,506 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $642,506 Insurance broker name SIDLES DUNCAN & ASSOCIATES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number
Policy instance	21
Number of Individuals Covered 122 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $20,503 Total amount of fees paid to insurance company USD $627 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,503 Amount paid for insurance broker fees 627 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number
Policy instance	19
Number of Individuals Covered 1238 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $169,900 Total amount of fees paid to insurance company USD $8,350 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $169,900 Amount paid for insurance broker fees 8350 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
KAISER FOUNDATION HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number
Policy instance	20
Number of Individuals Covered 1537 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $247,445 Total amount of fees paid to insurance company USD $17,536 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $247,445 Amount paid for insurance broker fees 17536 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	18
Insurance contract or identification number 227118 Number of Individuals Covered 991 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-01 Total amount of commissions paid to insurance broker USD $351,817 Total amount of fees paid to insurance company USD $7,098 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $351,817 Amount paid for insurance broker fees 7098 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	276428
Policy instance	17
Insurance contract or identification number 276428 Number of Individuals Covered 164 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $56,385 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Health Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $56,385 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOCIATES
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	2023358
Policy instance	1
Insurance contract or identification number 2023358 Number of Individuals Covered 1089 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $391,249 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $391,249 Insurance broker organization code? 3 Insurance broker name SIDLES DUNCAN & ASSOC INSURANCE
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	BCM001038
Policy instance	41
Insurance contract or identification number BCM001038 Number of Individuals Covered 6 Insurance policy start date 2010-05-03 Insurance policy end date 2011-04-03 Total amount of commissions paid to insurance broker USD $519 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	KM05733950
Policy instance	40
Insurance contract or identification number KM05733950 Number of Individuals Covered 83 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $1,275 Total amount of fees paid to insurance company USD $77 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number	5396464
Policy instance	20
Insurance contract or identification number 5396464 Number of Individuals Covered 116 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $2,105 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30019646
Policy instance	19
Insurance contract or identification number 30019646 Number of Individuals Covered 239 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $1,580 Vision Insurance Welfare Benefit Yes
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12214263
Policy instance	18
Insurance contract or identification number 12214263 Number of Individuals Covered 1963 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $12,703 Vision Insurance Welfare Benefit Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	17
Insurance contract or identification number G0004461 Number of Individuals Covered 281 Insurance policy start date 2010-05-01 Insurance policy end date 2011-05-01 Total amount of commissions paid to insurance broker USD $8,203 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 117614
Policy instance	16
Insurance contract or identification number LTD 117614 Number of Individuals Covered 137 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $519 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	15
Insurance contract or identification number LTD 112593 Number of Individuals Covered 1343 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $11,570 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	14
Insurance contract or identification number GL 138680 Number of Individuals Covered 1106 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $5,518 Life Insurance Welfare Benefit Yes
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL138676
Policy instance	12
Insurance contract or identification number GL138676 Number of Individuals Covered 141 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $2,571 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138673
Policy instance	11
Insurance contract or identification number GL 138673 Number of Individuals Covered 245 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $11,570 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 027860
Policy instance	10
Insurance contract or identification number GL 027860 Number of Individuals Covered 576 Insurance policy start date 2010-09-01 Insurance policy end date 2011-08-31 Total amount of commissions paid to insurance broker USD $1,448 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	ZH5888, 944762
Policy instance	9
Insurance contract or identification number ZH5888, 944762 Number of Individuals Covered 1038 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $362,674 Total amount of fees paid to insurance company USD $285 Health Insurance Welfare Benefit Yes
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	H54910, 944760
Policy instance	8
Insurance contract or identification number H54910, 944760 Number of Individuals Covered 138 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $24,292 Health Insurance Welfare Benefit Yes
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	0199041
Policy instance	7
Insurance contract or identification number 0199041 Number of Individuals Covered 2022 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $65,350 Dental Insurance Welfare Benefit Yes
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	228293
Policy instance	5
Insurance contract or identification number 228293 Number of Individuals Covered 69 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-01 Total amount of commissions paid to insurance broker USD $13,283 Total amount of fees paid to insurance company USD $1,500 Health Insurance Welfare Benefit Yes
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	114049
Policy instance	4
Insurance contract or identification number 114049 Number of Individuals Covered 853 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-01 Total amount of commissions paid to insurance broker USD $174,701 Total amount of fees paid to insurance company USD $19,775 Health Insurance Welfare Benefit Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AAH9
Policy instance	21
Insurance contract or identification number G000AAH9 Number of Individuals Covered 85 Insurance policy start date 2010-04-01 Insurance policy end date 2011-04-01 Total amount of commissions paid to insurance broker USD $395 Temporary Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AAH9
Policy instance	22
Insurance contract or identification number G000AAH9 Number of Individuals Covered 85 Insurance policy start date 2010-04-01 Insurance policy end date 2011-04-01 Total amount of commissions paid to insurance broker USD $1,328 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5396464
Policy instance	6
Insurance contract or identification number 5396464 Number of Individuals Covered 86 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $7,511 Dental Insurance Welfare Benefit Yes
SAFEGUARD HEALTH PLANS INC (National Association of Insurance Commissioners NAIC id number: 79014 )
Policy contract number	97285056
Policy instance	39
Insurance contract or identification number 97285056 Number of Individuals Covered 32 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $707 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	KMS05733950
Policy instance	38
Insurance contract or identification number KMS05733950 Number of Individuals Covered 91 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $813 Total amount of fees paid to insurance company USD $25 Dental Insurance Welfare Benefit Yes
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	27502
Policy instance	37
Insurance contract or identification number 27502 Number of Individuals Covered 188 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $22,041 Total amount of fees paid to insurance company USD $4,408 Health Insurance Welfare Benefit Yes
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	275730
Policy instance	36
Insurance contract or identification number 275730 Number of Individuals Covered 3452 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $434,920 Health Insurance Welfare Benefit Yes
AMERICAN SPECIALTY HEALTH PLANS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1388900-1388903
Policy instance	35
Insurance contract or identification number 1388900-1388903 Number of Individuals Covered 153 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $823 Other welfare benefits provided CHIROPRACTIC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 027860
Policy instance	34
Insurance contract or identification number GL 027860 Number of Individuals Covered 572 Insurance policy start date 2010-09-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $908 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138676
Policy instance	33
Insurance contract or identification number GL 138676 Number of Individuals Covered 141 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $1,462 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	31
Insurance contract or identification number G000702H Number of Individuals Covered 50 Insurance policy start date 2010-02-01 Insurance policy end date 2011-02-01 Total amount of commissions paid to insurance broker USD $1,290 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number
Policy instance	30
Number of Individuals Covered 17 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $15,172 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number
Policy instance	29
Number of Individuals Covered 238 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $95,058 Health Insurance Welfare Benefit Yes
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TS05336970
Policy instance	28
Insurance contract or identification number TS05336970 Number of Individuals Covered 1555 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $96,636 Total amount of fees paid to insurance company USD $2,103 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	TS05336970
Policy instance	27
Insurance contract or identification number TS05336970 Number of Individuals Covered 1906 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $18,756 Total amount of fees paid to insurance company USD $411 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12236504
Policy instance	26
Insurance contract or identification number 12236504 Number of Individuals Covered 751 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $2,452 Total amount of fees paid to insurance company USD $117 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	95-4402957
Policy instance	25
Insurance contract or identification number 95-4402957 Number of Individuals Covered 95 Insurance policy start date 2010-02-01 Insurance policy end date 2011-01-31 Total amount of commissions paid to insurance broker USD $14,575 Health Insurance Welfare Benefit Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G0004461
Policy instance	23
Insurance contract or identification number G0004461 Number of Individuals Covered 978 Insurance policy start date 2010-05-01 Insurance policy end date 2011-05-01 Total amount of commissions paid to insurance broker USD $2,143 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	39723
Policy instance	3
Insurance contract or identification number 39723 Number of Individuals Covered 55 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-01 Total amount of commissions paid to insurance broker USD $15,976 Health Insurance Welfare Benefit Yes
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	600306
Policy instance	2
Insurance contract or identification number 600306 Number of Individuals Covered 1529 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-01 Total amount of commissions paid to insurance broker USD $261,006 Total amount of fees paid to insurance company USD $25,475 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	1
Insurance contract or identification number 227118 Number of Individuals Covered 650 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-01 Total amount of commissions paid to insurance broker USD $133,071 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
AMERICAN SPECIALTY HEALTH PLANS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1388901-1388903
Policy instance	24
Insurance contract or identification number 1388901-1388903 Number of Individuals Covered 181 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $823 Other welfare benefits provided CHROPRACTIC/ACUPUNCTURE Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	32
Insurance contract or identification number G000702H Number of Individuals Covered 221 Insurance policy start date 2010-02-01 Insurance policy end date 2011-02-01 Total amount of commissions paid to insurance broker USD $862 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	13
Insurance contract or identification number GL 138677 Number of Individuals Covered 606 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $23,802 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	H54910,944760
Policy instance	11
Insurance contract or identification number H54910,944760 Number of Individuals Covered 81 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $20,505 Total amount of fees paid to insurance company USD $512 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $20,505 Amount paid for insurance broker fees 512 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	VAR 203203
Policy instance	12
Insurance contract or identification number VAR 203203 Number of Individuals Covered 257 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $2,080 Total amount of fees paid to insurance company USD $188 Temporary Disability Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $2,080 Amount paid for insurance broker fees 188 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD 112593
Policy instance	13
Insurance contract or identification number LTD 112593 Number of Individuals Covered 1212 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $11,186 Total amount of fees paid to insurance company USD $1,448 Long Term Disability Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $11,186 Amount paid for insurance broker fees 1448 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL138673
Policy instance	14
Insurance contract or identification number GL138673 Number of Individuals Covered 250 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $2,669 Total amount of fees paid to insurance company USD $414 Life Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $2,669 Amount paid for insurance broker fees 414 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138677
Policy instance	15
Insurance contract or identification number GL 138677 Number of Individuals Covered 529 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $21,437 Total amount of fees paid to insurance company USD $2,610 Life Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $21,437 Amount paid for insurance broker fees 2610 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 138680
Policy instance	17
Insurance contract or identification number GL 138680 Number of Individuals Covered 1030 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $5,656 Total amount of fees paid to insurance company USD $755 Life Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $5,656 Amount paid for insurance broker fees 755 Insurance broker name SIDLES DUNCAN & ASSOCIATES
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	UF 04461
Policy instance	9
Insurance contract or identification number UF 04461 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-30 Total amount of commissions paid to insurance broker USD $51,471 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $51,471 Insurance broker name SIDLES DUNCAN & ASSOCIATES
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	H54911,944762
Policy instance	10
Insurance contract or identification number H54911,944762 Number of Individuals Covered 632 Insurance policy start date 2009-05-01 Insurance policy end date 2010-04-30 Total amount of commissions paid to insurance broker USD $205,239 Total amount of fees paid to insurance company USD $3,874 Health Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $205,239 Amount paid for insurance broker fees 3874 Insurance broker name SIDLES DUNCAN & ASSOCIATES
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	004I11452
Policy instance	8
Insurance contract or identification number 004I11452 Number of Individuals Covered 76 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $6,734 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $6,734 Insurance broker name SIDLES DUNCAN & ASSOCIATES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	114049
Policy instance	7
Insurance contract or identification number 114049 Number of Individuals Covered 695 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $117,959 Health Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $117,959 Insurance broker organization code? 5 Insurance broker name SIDLES DUNCAN & ASSOCIATES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	227118
Policy instance	6
Insurance contract or identification number 227118 Number of Individuals Covered 567 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-30 Total amount of commissions paid to insurance broker USD $101,246 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $101,246 Insurance broker organization code? 5 Insurance broker name SIDLES DUNCAN & ASSOCIATES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	39723
Policy instance	5
Insurance contract or identification number 39723 Number of Individuals Covered 79 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-30 Total amount of commissions paid to insurance broker USD $12,289 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $12,289 Insurance broker name SIDLES DUNCAN & ASSOCIATES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	600306
Policy instance	4
Insurance contract or identification number 600306 Number of Individuals Covered 1241 Insurance policy start date 2009-05-01 Insurance policy end date 2010-04-30 Total amount of commissions paid to insurance broker USD $226,046 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $226,046 Insurance broker organization code? 5 Insurance broker name SIDLES DUNCAN & ASSOCIATES INSURANC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	228293
Policy instance	3
Insurance contract or identification number 228293 Number of Individuals Covered 86 Insurance policy start date 2009-04-02 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $8,170 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $8,171 Insurance broker organization code? 5 Insurance broker name SIDLES DUNCAN & ASSOCIATES
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	811330
Policy instance	2
Insurance contract or identification number 811330 Number of Individuals Covered 2888 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $287,616 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? Yes Commission paid to Insurance Broker USD $252,977 Insurance broker organization code? 5 Insurance broker name SIDLES DUNCAN & ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GL138676
Policy instance	18
Insurance contract or identification number GL138676 Number of Individuals Covered 76 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $1,328 Total amount of fees paid to insurance company USD $151 Life Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $1,328 Amount paid for insurance broker fees 151 Insurance broker name SIDLES DUNACAN & ASSOCIATES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12214263
Policy instance	20
Insurance contract or identification number 12214263 Number of Individuals Covered 2176 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $11,927 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $11,927 Insurance broker name SHEILA HARTMAN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	35
Insurance contract or identification number G000702H Number of Individuals Covered 49 Insurance policy start date 2009-02-01 Insurance policy end date 2010-02-01 Total amount of commissions paid to insurance broker USD $997 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $997 Insurance broker name SIDLES DUNCAN & ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000702H
Policy instance	34
Insurance contract or identification number G000702H Number of Individuals Covered 226 Insurance policy start date 2009-02-01 Insurance policy end date 2010-02-01 Total amount of commissions paid to insurance broker USD $824 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $824 Insurance broker name SIDLES DUNCAN & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 027860
Policy instance	16
Insurance contract or identification number GL 027860 Number of Individuals Covered 560 Insurance policy start date 2009-09-01 Insurance policy end date 2010-08-31 Total amount of commissions paid to insurance broker USD $1,599 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $1,599 Insurance broker name SIDLES DUNCAN & ASSOCIATES
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number
Policy instance	33
Number of Individuals Covered 153 Insurance policy start date 2009-02-01 Insurance policy end date 2010-01-31 Total amount of commissions paid to insurance broker USD $27,255 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $27,255 Insurance broker name SIDLES DUNCAN & ASSOCIATES
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number
Policy instance	32
Number of Individuals Covered 58 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $18,220 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $18,220 Insurance broker name SIDLES DUNCAN & ASSOCIATES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	KM05733950
Policy instance	31
Insurance contract or identification number KM05733950 Number of Individuals Covered 88 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $996 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $996 Insurance broker organization code? 5 Insurance broker name SIDLES DUNCAN & ASSOCIATES
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	0199041
Policy instance	29
Insurance contract or identification number 0199041 Number of Individuals Covered 1727 Insurance policy start date 2009-05-01 Insurance policy end date 2010-04-30 Total amount of commissions paid to insurance broker USD $51,471 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $51,471 Insurance broker name SIDLES DUNCAN & ASSOCIATES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12236504
Policy instance	28
Insurance contract or identification number 12236504 Number of Individuals Covered 555 Insurance policy start date 2009-05-01 Insurance policy end date 2010-04-30 Total amount of commissions paid to insurance broker USD $2,339 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $2,339 Insurance broker name SIDLES DUNCAN & ASSOCIATES
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	KM05733950
Policy instance	30
Insurance contract or identification number KM05733950 Number of Individuals Covered 140 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $1,124 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $1,124 Insurance broker name SIDLES DUNCAN & ASSOCIATES
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number	95-4402957
Policy instance	27
Insurance contract or identification number 95-4402957 Number of Individuals Covered 242 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $80,427 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $80,427 Insurance broker name SIDLES DUNCAN & ASSOCIATES
AMERICAN SPECIALTY HEALTH PLANS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1388901-1388903
Policy instance	26
Insurance contract or identification number 1388901-1388903 Number of Individuals Covered 271 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $1,358 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided CHRIROPRACTIC/ACUPUNCTURE Commission paid to Insurance Broker USD $1,358 Insurance broker name SIDLES DUNCAN & ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL04461
Policy instance	25
Insurance contract or identification number GVTL04461 Number of Individuals Covered 271 Insurance policy start date 2009-05-01 Insurance policy end date 2010-05-01 Total amount of commissions paid to insurance broker USD $8,537 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $8,537 Insurance broker name SIDLES DUNCAN & ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AAH9
Policy instance	24
Insurance contract or identification number G000AAH9 Number of Individuals Covered 79 Insurance policy start date 2009-04-01 Insurance policy end date 2010-04-01 Total amount of commissions paid to insurance broker USD $1,272 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $1,272 Insurance broker name SIDLES DUNCAN & ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AAH9
Policy instance	23
Insurance contract or identification number G000AAH9 Number of Individuals Covered 79 Insurance policy start date 2009-04-01 Insurance policy end date 2010-04-01 Total amount of commissions paid to insurance broker USD $366 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $366 Insurance broker name SIDLES DUNCAN ASSOCIATES
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number	5396464
Policy instance	22
Insurance contract or identification number 5396464 Number of Individuals Covered 101 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $1,890 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $1,890 Insurance broker name SIDLES DUNCAN & ASSOCIATES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	30019646
Policy instance	21
Insurance contract or identification number 30019646 Number of Individuals Covered 249 Insurance policy start date 2010-05-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,056 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $1,056 Insurance broker name DUBLIN INSURANCE SERVICES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL138676
Policy instance	19
Insurance contract or identification number GL138676 Number of Individuals Covered 76 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $1,326 Total amount of fees paid to insurance company USD $151 Life Insurance Welfare Benefit Yes Amount paid for insurance broker fees 1872 Insurance broker name SIDLES DUNCAN & ASSOCIATES
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	US358854
Policy instance	1
Insurance contract or identification number US358854 Number of Individuals Covered 1483 Insurance policy start date 2009-01-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $252,977 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? Yes Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $252,977 Insurance broker organization code? 5 Insurance broker name SIDLES DUNCAN & ASSOCIATES