401k Plan data: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN plan

BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN
Plan identification number	501

BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

BRISTOL FARMS, INC. has sponsored the creation of one or more 401k plans.

Company Name: BRISTOL FARMS, INC.

Employer identification number (EIN): 954502352

NAIC Classification: 445110
NAIC Description: Supermarkets and Other Grocery (except Convenience) Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-03-01
501 2015-03-01 YOLANDA PEPIN
501 2014-03-01 YOLANDA PEPIN
501 2013-03-01 YOLANDA PEPIN
501 2012-03-01 YOLANDA PEPIN YOLANDA PEPIN 2013-09-30
501 2011-03-01 YOLANDA PEPIN
501 2009-03-01
501 2009-03-01 YOLIE PEPIN

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2016-03-01
501	2015-03-01	YOLANDA PEPIN
501	2014-03-01	YOLANDA PEPIN
501	2013-03-01	YOLANDA PEPIN
501	2012-03-01	YOLANDA PEPIN	YOLANDA PEPIN	2013-09-30
501	2011-03-01	YOLANDA PEPIN
501	2009-03-01
501	2009-03-01	YOLIE PEPIN

Plan Statistics for BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN

401k plan membership statisitcs for BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN

Measure Date Value
2016: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-03-01 1,351
Total number of active participants reported on line 7a of the Form 5500 2016-03-01 1,294
Number of retired or separated participants receiving benefits 2016-03-01 0
Number of other retired or separated participants entitled to future benefits 2016-03-01 0
Total of all active and inactive participants 2016-03-01 1,294
2015: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-03-01 1,419
Total number of active participants reported on line 7a of the Form 5500 2015-03-01 1,351
Number of retired or separated participants receiving benefits 2015-03-01 0
Number of other retired or separated participants entitled to future benefits 2015-03-01 0
Total of all active and inactive participants 2015-03-01 1,351
2014: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-03-01 1,286
Total number of active participants reported on line 7a of the Form 5500 2014-03-01 1,414
Number of retired or separated participants receiving benefits 2014-03-01 5
Number of other retired or separated participants entitled to future benefits 2014-03-01 0
Total of all active and inactive participants 2014-03-01 1,419
2013: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-03-01 1,218
Total number of active participants reported on line 7a of the Form 5500 2013-03-01 1,276
Number of retired or separated participants receiving benefits 2013-03-01 10
Number of other retired or separated participants entitled to future benefits 2013-03-01 0
Total of all active and inactive participants 2013-03-01 1,286
2012: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-03-01 1,185
Total number of active participants reported on line 7a of the Form 5500 2012-03-01 1,207
Number of retired or separated participants receiving benefits 2012-03-01 11
Number of other retired or separated participants entitled to future benefits 2012-03-01 0
Total of all active and inactive participants 2012-03-01 1,218
2011: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-03-01 1,236
Total number of active participants reported on line 7a of the Form 5500 2011-03-01 1,179
Number of retired or separated participants receiving benefits 2011-03-01 6
Number of other retired or separated participants entitled to future benefits 2011-03-01 0
Total of all active and inactive participants 2011-03-01 1,185
2009: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-03-01 1,666
Total number of active participants reported on line 7a of the Form 5500 2009-03-01 1,388
Number of retired or separated participants receiving benefits 2009-03-01 22
Number of other retired or separated participants entitled to future benefits 2009-03-01 0
Total of all active and inactive participants 2009-03-01 1,410

Measure	Date	Value
2016: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-03-01	1,351
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	1,294
Number of retired or separated participants receiving benefits	2016-03-01	0
Number of other retired or separated participants entitled to future benefits	2016-03-01	0
Total of all active and inactive participants	2016-03-01	1,294
2015: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-03-01	1,419
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	1,351
Number of retired or separated participants receiving benefits	2015-03-01	0
Number of other retired or separated participants entitled to future benefits	2015-03-01	0
Total of all active and inactive participants	2015-03-01	1,351
2014: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-03-01	1,286
Total number of active participants reported on line 7a of the Form 5500	2014-03-01	1,414
Number of retired or separated participants receiving benefits	2014-03-01	5
Number of other retired or separated participants entitled to future benefits	2014-03-01	0
Total of all active and inactive participants	2014-03-01	1,419
2013: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-03-01	1,218
Total number of active participants reported on line 7a of the Form 5500	2013-03-01	1,276
Number of retired or separated participants receiving benefits	2013-03-01	10
Number of other retired or separated participants entitled to future benefits	2013-03-01	0
Total of all active and inactive participants	2013-03-01	1,286
2012: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-03-01	1,185
Total number of active participants reported on line 7a of the Form 5500	2012-03-01	1,207
Number of retired or separated participants receiving benefits	2012-03-01	11
Number of other retired or separated participants entitled to future benefits	2012-03-01	0
Total of all active and inactive participants	2012-03-01	1,218
2011: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-03-01	1,236
Total number of active participants reported on line 7a of the Form 5500	2011-03-01	1,179
Number of retired or separated participants receiving benefits	2011-03-01	6
Number of other retired or separated participants entitled to future benefits	2011-03-01	0
Total of all active and inactive participants	2011-03-01	1,185
2009: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-03-01	1,666
Total number of active participants reported on line 7a of the Form 5500	2009-03-01	1,388
Number of retired or separated participants receiving benefits	2009-03-01	22
Number of other retired or separated participants entitled to future benefits	2009-03-01	0
Total of all active and inactive participants	2009-03-01	1,410

Form 5500 Responses for BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN

2016: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Submission has been amended	No
2016-03-01	This submission is the final filing	No
2016-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-03-01	Plan is a collectively bargained plan	No
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2015: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Submission has been amended	No
2015-03-01	This submission is the final filing	No
2015-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-03-01	Plan is a collectively bargained plan	No
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2014: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2014 form 5500 responses
2014-03-01	Type of plan entity	Single employer plan
2014-03-01	Submission has been amended	No
2014-03-01	This submission is the final filing	No
2014-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-03-01	Plan is a collectively bargained plan	No
2014-03-01	Plan funding arrangement – Insurance	Yes
2014-03-01	Plan benefit arrangement – Insurance	Yes
2013: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2013 form 5500 responses
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	Submission has been amended	No
2013-03-01	This submission is the final filing	No
2013-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-03-01	Plan is a collectively bargained plan	No
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes
2012: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	Submission has been amended	No
2012-03-01	This submission is the final filing	No
2012-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-03-01	Plan is a collectively bargained plan	No
2012-03-01	Plan funding arrangement – Insurance	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes
2011: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2011 form 5500 responses
2011-03-01	Type of plan entity	Single employer plan
2011-03-01	Submission has been amended	No
2011-03-01	This submission is the final filing	No
2011-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-03-01	Plan is a collectively bargained plan	No
2011-03-01	Plan funding arrangement – Insurance	Yes
2011-03-01	Plan benefit arrangement – Insurance	Yes
2009: BRISTOL FARMS, INC. GROUP HEALTH & WELFARE PLAN 2009 form 5500 responses
2009-03-01	Type of plan entity	Single employer plan
2009-03-01	Submission has been amended	No
2009-03-01	This submission is the final filing	No
2009-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-03-01	Plan is a collectively bargained plan	No
2009-03-01	Plan funding arrangement – Insurance	Yes
2009-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	1114
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $133,467
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,316,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $133,467
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

121618/602384

Policy instance

Insurance contract or identification number	121618/602384
Number of Individuals Covered	410
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $75,832
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,066,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $75,832
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

COM589

Policy instance

Insurance contract or identification number	COM589
Number of Individuals Covered	1351
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $2,513
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $25,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,513
Insurance broker organization code?	3
Insurance broker name	UNKNOWN

SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )

Policy contract number

156778

Policy instance

Insurance contract or identification number	156778
Number of Individuals Covered	645
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $75,427
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

156778

Policy instance

Insurance contract or identification number	156778
Number of Individuals Covered	882
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $3,912
Total amount of fees paid to insurance company	USD $6,773
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $369,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,912
Amount paid for insurance broker fees	6773
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION ADDMINSTRATION FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

COM589

Policy instance

Insurance contract or identification number	COM589
Number of Individuals Covered	1474
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $2,573
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $25,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,573
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

602384

Policy instance

Insurance contract or identification number	602384
Number of Individuals Covered	28
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $6,266
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $161,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,266
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0156778

Policy instance

Insurance contract or identification number	0156778
Number of Individuals Covered	817
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $2,722
Total amount of fees paid to insurance company	USD $5,461
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $326,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,722
Amount paid for insurance broker fees	5461
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION AND SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

121618

Policy instance

Insurance contract or identification number	121618
Number of Individuals Covered	449
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $66,603
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,961,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66,603
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	937
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $2,023
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $56,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,023
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	457
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $111,408
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,138,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $111,408
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	1414
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $17,933
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $505,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,933
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )

Policy contract number

0156778

Policy instance

Insurance contract or identification number	0156778
Number of Individuals Covered	682
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $80,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	1274
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $5,699
Total amount of fees paid to insurance company	USD $377
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $162,937
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,699
Amount paid for insurance broker fees	377
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

121618

Policy instance

Insurance contract or identification number	121618
Number of Individuals Covered	469
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $68,236
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,004,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $68,236
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

COM589

Policy instance

Insurance contract or identification number	COM589
Number of Individuals Covered	1223
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $2,152
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,520
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	ALLIANT INSURANCE SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

602384

Policy instance

Insurance contract or identification number	602384
Number of Individuals Covered	39
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $6,141
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $200,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,141
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	505
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $127,248
Total amount of fees paid to insurance company	USD $8,424
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,637,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $127,248
Amount paid for insurance broker fees	8424
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	1274
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $1,769
Total amount of fees paid to insurance company	USD $117
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $50,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,769
Amount paid for insurance broker fees	117
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

602384

Policy instance

Insurance contract or identification number	602384
Number of Individuals Covered	45
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $6,240
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $184,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,240
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	1207
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $6,190
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $154,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,190
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

121618

Policy instance

Insurance contract or identification number	121618
Number of Individuals Covered	486
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $72,197
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,117,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,197
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	488
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $149,901
Total amount of fees paid to insurance company	USD $19,918
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,742,943
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $149,901
Amount paid for insurance broker fees	19918
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	924
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $2,141
Total amount of fees paid to insurance company	USD $284
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $53,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,141
Amount paid for insurance broker fees	284
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

COM589

Policy instance

Insurance contract or identification number	COM589
Number of Individuals Covered	1217
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $2,135
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,355
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
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	1179
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $6,512
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $161,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

COM589

Policy instance

Insurance contract or identification number	COM589
Number of Individuals Covered	1192
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $2,108
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,084
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

121618

Policy instance

Insurance contract or identification number	121618
Number of Individuals Covered	324
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $80,665
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,166,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	132
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $2,363
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $58,631
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

602384

Policy instance

Insurance contract or identification number	602384
Number of Individuals Covered	30
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $6,351
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $168,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	827
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $136,536
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,387,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	542
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $137,978
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,042,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $137,978
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	1179
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $7,588
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $167,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,588
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

121618

Policy instance

Insurance contract or identification number	121618
Number of Individuals Covered	357
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $71,861
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,370,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $71,861
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

602384

Policy instance

Insurance contract or identification number	602384
Number of Individuals Covered	37
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $6,645
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $199,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,645
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

860324-100-200

Policy instance

Insurance contract or identification number	860324-100-200
Number of Individuals Covered	431
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $10,242
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,242
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

COM589

Policy instance

Insurance contract or identification number	COM589
Number of Individuals Covered	1462
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $2,329
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $23,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,329
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

154547

Policy instance

Insurance contract or identification number	154547
Number of Individuals Covered	912
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $2,822
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $62,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,822
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

860324-001-003

Policy instance

Insurance contract or identification number	860324-001-003
Number of Individuals Covered	448
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $4,656
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,656
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

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Company Name:	BRISTOL FARMS, INC.
Employer identification number (EIN):	954502352
NAIC Classification:	445110
NAIC Description:	Supermarkets and Other Grocery (except Convenience) Stores