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BODEGA LATINA HEALTH BENEFITS 401k Plan overview

Plan NameBODEGA LATINA HEALTH BENEFITS
Plan identification number 501

BODEGA LATINA HEALTH BENEFITS Benefits

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

401k Sponsoring company profile

CHEDRAUI USA, INC. has sponsored the creation of one or more 401k plans.

Company Name:CHEDRAUI USA, INC.
Employer identification number (EIN):954517472
NAIC Classification:445110
NAIC Description:Supermarkets and Other Grocery (except Convenience) Stores

Additional information about CHEDRAUI USA, INC.

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 2507477

More information about CHEDRAUI USA, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BODEGA LATINA HEALTH BENEFITS

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-10-01JACK HOOK2023-04-25
5012020-10-01JACK HOOK2022-07-12
5012019-10-01JACK HOOK2021-07-08
5012018-10-01JACK HOOK2020-07-10
5012017-10-01JACK HOOK2019-07-08
5012016-10-01
5012015-10-01JACK HOOK
5012014-10-01JACK HOOK
5012013-10-01JACK HOOK
5012012-10-01JACK HOOK
5012011-10-01JACK HOOK
5012010-10-01JACK HOOK
5012009-10-01JACK HOOK
5012008-10-01

Plan Statistics for BODEGA LATINA HEALTH BENEFITS

401k plan membership statisitcs for BODEGA LATINA HEALTH BENEFITS

Measure Date Value
2021: BODEGA LATINA HEALTH BENEFITS 2021 401k membership
Total participants, beginning-of-year2021-10-013,109
Total number of active participants reported on line 7a of the Form 55002021-10-013,338
Number of retired or separated participants receiving benefits2021-10-010
Number of other retired or separated participants entitled to future benefits2021-10-010
Total of all active and inactive participants2021-10-013,338
Number of employers contributing to the scheme2021-10-010
2020: BODEGA LATINA HEALTH BENEFITS 2020 401k membership
Total participants, beginning-of-year2020-10-011,849
Total number of active participants reported on line 7a of the Form 55002020-10-013,104
Number of retired or separated participants receiving benefits2020-10-015
Number of other retired or separated participants entitled to future benefits2020-10-010
Total of all active and inactive participants2020-10-013,109
Number of employers contributing to the scheme2020-10-010
2019: BODEGA LATINA HEALTH BENEFITS 2019 401k membership
Total participants, beginning-of-year2019-10-011,844
Total number of active participants reported on line 7a of the Form 55002019-10-011,841
Number of retired or separated participants receiving benefits2019-10-018
Number of other retired or separated participants entitled to future benefits2019-10-010
Total of all active and inactive participants2019-10-011,849
Number of employers contributing to the scheme2019-10-010
2018: BODEGA LATINA HEALTH BENEFITS 2018 401k membership
Total participants, beginning-of-year2018-10-011,972
Total number of active participants reported on line 7a of the Form 55002018-10-011,841
Number of retired or separated participants receiving benefits2018-10-013
Number of other retired or separated participants entitled to future benefits2018-10-010
Total of all active and inactive participants2018-10-011,844
Number of employers contributing to the scheme2018-10-010
2017: BODEGA LATINA HEALTH BENEFITS 2017 401k membership
Total participants, beginning-of-year2017-10-012,072
Total number of active participants reported on line 7a of the Form 55002017-10-011,971
Number of retired or separated participants receiving benefits2017-10-011
Number of other retired or separated participants entitled to future benefits2017-10-010
Total of all active and inactive participants2017-10-011,972
Number of employers contributing to the scheme2017-10-010
2016: BODEGA LATINA HEALTH BENEFITS 2016 401k membership
Total participants, beginning-of-year2016-10-011,956
Total number of active participants reported on line 7a of the Form 55002016-10-012,072
Number of retired or separated participants receiving benefits2016-10-010
Number of other retired or separated participants entitled to future benefits2016-10-010
Total of all active and inactive participants2016-10-012,072
2015: BODEGA LATINA HEALTH BENEFITS 2015 401k membership
Total participants, beginning-of-year2015-10-011,628
Total number of active participants reported on line 7a of the Form 55002015-10-011,952
Number of retired or separated participants receiving benefits2015-10-014
Number of other retired or separated participants entitled to future benefits2015-10-010
Total of all active and inactive participants2015-10-011,956
2014: BODEGA LATINA HEALTH BENEFITS 2014 401k membership
Total participants, beginning-of-year2014-10-011,624
Total number of active participants reported on line 7a of the Form 55002014-10-011,624
Number of retired or separated participants receiving benefits2014-10-014
Number of other retired or separated participants entitled to future benefits2014-10-010
Total of all active and inactive participants2014-10-011,628
2013: BODEGA LATINA HEALTH BENEFITS 2013 401k membership
Total participants, beginning-of-year2013-10-011,471
Total number of active participants reported on line 7a of the Form 55002013-10-011,623
Number of retired or separated participants receiving benefits2013-10-011
Number of other retired or separated participants entitled to future benefits2013-10-010
Total of all active and inactive participants2013-10-011,624
2012: BODEGA LATINA HEALTH BENEFITS 2012 401k membership
Total participants, beginning-of-year2012-10-011,211
Total number of active participants reported on line 7a of the Form 55002012-10-011,468
Number of retired or separated participants receiving benefits2012-10-013
Number of other retired or separated participants entitled to future benefits2012-10-010
Total of all active and inactive participants2012-10-011,471
2011: BODEGA LATINA HEALTH BENEFITS 2011 401k membership
Total participants, beginning-of-year2011-10-011,173
Total number of active participants reported on line 7a of the Form 55002011-10-011,208
Number of retired or separated participants receiving benefits2011-10-013
Number of other retired or separated participants entitled to future benefits2011-10-010
Total of all active and inactive participants2011-10-011,211
2010: BODEGA LATINA HEALTH BENEFITS 2010 401k membership
Total participants, beginning-of-year2010-10-01639
Total number of active participants reported on line 7a of the Form 55002010-10-011,162
Number of retired or separated participants receiving benefits2010-10-0111
Number of other retired or separated participants entitled to future benefits2010-10-010
Total of all active and inactive participants2010-10-011,173
2009: BODEGA LATINA HEALTH BENEFITS 2009 401k membership
Total participants, beginning-of-year2009-10-01559
Total number of active participants reported on line 7a of the Form 55002009-10-01635
Number of retired or separated participants receiving benefits2009-10-014
Number of other retired or separated participants entitled to future benefits2009-10-010
Total of all active and inactive participants2009-10-01639

Form 5500 Responses for BODEGA LATINA HEALTH BENEFITS

2021: BODEGA LATINA HEALTH BENEFITS 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan funding arrangement – General assets of the sponsorYes
2021-10-01Plan benefit arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – General assets of the sponsorYes
2020: BODEGA LATINA HEALTH BENEFITS 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan funding arrangement – General assets of the sponsorYes
2020-10-01Plan benefit arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – General assets of the sponsorYes
2019: BODEGA LATINA HEALTH BENEFITS 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan funding arrangement – General assets of the sponsorYes
2019-10-01Plan benefit arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – General assets of the sponsorYes
2018: BODEGA LATINA HEALTH BENEFITS 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan funding arrangement – General assets of the sponsorYes
2018-10-01Plan benefit arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – General assets of the sponsorYes
2017: BODEGA LATINA HEALTH BENEFITS 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan funding arrangement – General assets of the sponsorYes
2017-10-01Plan benefit arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – General assets of the sponsorYes
2016: BODEGA LATINA HEALTH BENEFITS 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)No
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan funding arrangement – General assets of the sponsorYes
2016-10-01Plan benefit arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – General assets of the sponsorYes
2015: BODEGA LATINA HEALTH BENEFITS 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – General assets of the sponsorYes
2015-10-01Plan benefit arrangement – InsuranceYes
2014: BODEGA LATINA HEALTH BENEFITS 2014 form 5500 responses
2014-10-01Type of plan entitySingle employer plan
2014-10-01Submission has been amendedNo
2014-10-01This submission is the final filingNo
2014-10-01This return/report is a short plan year return/report (less than 12 months)No
2014-10-01Plan is a collectively bargained planNo
2014-10-01Plan funding arrangement – General assets of the sponsorYes
2014-10-01Plan benefit arrangement – InsuranceYes
2013: BODEGA LATINA HEALTH BENEFITS 2013 form 5500 responses
2013-10-01Type of plan entitySingle employer plan
2013-10-01Submission has been amendedNo
2013-10-01This submission is the final filingNo
2013-10-01This return/report is a short plan year return/report (less than 12 months)No
2013-10-01Plan is a collectively bargained planNo
2013-10-01Plan funding arrangement – General assets of the sponsorYes
2013-10-01Plan benefit arrangement – InsuranceYes
2012: BODEGA LATINA HEALTH BENEFITS 2012 form 5500 responses
2012-10-01Type of plan entitySingle employer plan
2012-10-01Submission has been amendedNo
2012-10-01This submission is the final filingNo
2012-10-01This return/report is a short plan year return/report (less than 12 months)No
2012-10-01Plan is a collectively bargained planNo
2012-10-01Plan funding arrangement – General assets of the sponsorYes
2012-10-01Plan benefit arrangement – InsuranceYes
2011: BODEGA LATINA HEALTH BENEFITS 2011 form 5500 responses
2011-10-01Type of plan entitySingle employer plan
2011-10-01Submission has been amendedNo
2011-10-01This submission is the final filingNo
2011-10-01This return/report is a short plan year return/report (less than 12 months)No
2011-10-01Plan is a collectively bargained planNo
2011-10-01Plan funding arrangement – General assets of the sponsorYes
2011-10-01Plan benefit arrangement – InsuranceYes
2010: BODEGA LATINA HEALTH BENEFITS 2010 form 5500 responses
2010-10-01Type of plan entitySingle employer plan
2010-10-01Submission has been amendedNo
2010-10-01This submission is the final filingNo
2010-10-01This return/report is a short plan year return/report (less than 12 months)No
2010-10-01Plan is a collectively bargained planNo
2010-10-01Plan funding arrangement – InsuranceYes
2010-10-01Plan benefit arrangement – InsuranceYes
2009: BODEGA LATINA HEALTH BENEFITS 2009 form 5500 responses
2009-10-01Type of plan entitySingle employer plan
2009-10-01Submission has been amendedNo
2009-10-01This submission is the final filingNo
2009-10-01This return/report is a short plan year return/report (less than 12 months)No
2009-10-01Plan is a collectively bargained planNo
2009-10-01Plan funding arrangement – InsuranceYes
2009-10-01Plan benefit arrangement – InsuranceYes
2008: BODEGA LATINA HEALTH BENEFITS 2008 form 5500 responses
2008-10-01Type of plan entitySingle employer plan
2008-10-01Submission has been amendedNo
2008-10-01This submission is the final filingNo
2008-10-01This return/report is a short plan year return/report (less than 12 months)No
2008-10-01Plan is a collectively bargained planNo

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AXSK
Policy instance 7
Insurance contract or identification numberGLUG0AXSK
Number of Individuals Covered1448
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $361,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number8837934
Policy instance 1
Insurance contract or identification number8837934
Number of Individuals Covered1890
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $146,028
Total amount of fees paid to insurance companyUSD $21,761
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $587,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $129,499
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number279778
Policy instance 2
Insurance contract or identification number279778
Number of Individuals Covered2432
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $17,926
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,169,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees17926
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberR1070A
Policy instance 3
Insurance contract or identification numberR1070A
Number of Individuals Covered189
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $68,827
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,492,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $50,840
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0292540
Policy instance 4
Insurance contract or identification numberR0292540
Number of Individuals Covered4
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $112
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $1,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number802423
Policy instance 5
Insurance contract or identification number802423
Number of Individuals Covered1714
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $208,630
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $796,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $208,630
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number603533
Policy instance 6
Insurance contract or identification number603533
Number of Individuals Covered290
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $515
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $1,694,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees515
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number8837934
Policy instance 1
Insurance contract or identification number8837934
Number of Individuals Covered519
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $88,830
Total amount of fees paid to insurance companyUSD $13,222
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $306,846
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $68,122
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number603533
Policy instance 2
Insurance contract or identification number603533
Number of Individuals Covered26
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $519
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $98,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees261
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number279778
Policy instance 3
Insurance contract or identification number279778
Number of Individuals Covered2739
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $35,622
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,617,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees35622
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberR1070A,B,C
Policy instance 4
Insurance contract or identification numberR1070A,B,C
Number of Individuals Covered208
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,615,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0292540
Policy instance 5
Insurance contract or identification numberR0292540
Number of Individuals Covered4
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $124
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $1,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $91
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number230817
Policy instance 6
Insurance contract or identification number230817
Number of Individuals Covered311
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $3,123
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,578,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees3123
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number802647
Policy instance 7
Insurance contract or identification number802647
Number of Individuals Covered1506
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $252,454
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $497,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $252,454
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AXSK
Policy instance 8
Insurance contract or identification numberGLUG0AXSK
Number of Individuals Covered1643
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $53,126
Total amount of fees paid to insurance companyUSD $4,579
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $459,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,126
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerOTHER COMPENSATION
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number8837934
Policy instance 2
Insurance contract or identification number8837934
Number of Individuals Covered891
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $128,661
Total amount of fees paid to insurance companyUSD $16,550
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $271,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $125,538
Amount paid for insurance broker fees15862
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number279778
Policy instance 3
Insurance contract or identification number279778
Number of Individuals Covered2875
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $8,732
Total amount of fees paid to insurance companyUSD $17,282
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,609,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,732
Amount paid for insurance broker fees17282
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberR1070B/R1070A
Policy instance 4
Insurance contract or identification numberR1070B/R1070A
Number of Individuals Covered220
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,548,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0292540
Policy instance 5
Insurance contract or identification numberR0292540
Number of Individuals Covered4
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $124
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $1,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $91
Amount paid for insurance broker fees0
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number933065
Policy instance 6
Insurance contract or identification number933065
Number of Individuals Covered44
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number13264
Policy instance 1
Insurance contract or identification number13264
Number of Individuals Covered2502
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $63,252
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $277,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,240
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0162073
Policy instance 7
Insurance contract or identification number0162073
Number of Individuals Covered1626
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $147,941
Total amount of fees paid to insurance companyUSD $5,538
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $462,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $118,126
Amount paid for insurance broker fees108
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number230817
Policy instance 8
Insurance contract or identification number230817
Number of Individuals Covered370
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $-287
Total amount of fees paid to insurance companyUSD $240
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $1,588,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $-287
Amount paid for insurance broker fees240
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AXSK
Policy instance 9
Insurance contract or identification numberGLUG0AXSK
Number of Individuals Covered1770
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $120,055
Total amount of fees paid to insurance companyUSD $3,726
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $323,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $120,055
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerOTHER COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0AXSK
Policy instance 9
Insurance contract or identification numberGUC0AXSK
Number of Individuals Covered599
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $33,820
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $225,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,820
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number230817
Policy instance 15
Insurance contract or identification number230817
Number of Individuals Covered347
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,444,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 )
Policy contract number5481497
Policy instance 14
Insurance contract or identification number5481497
Number of Individuals Covered20
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $74
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees74
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number13264
Policy instance 1
Insurance contract or identification number13264
Number of Individuals Covered2496
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $111,040
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $332,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,583
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AXSK
Policy instance 4
Insurance contract or identification numberGVTL0AXSK
Number of Individuals Covered693
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $33,927
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $226,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,927
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number603533
Policy instance 3
Insurance contract or identification number603533
Number of Individuals Covered31
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $405
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $112,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees405
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number279778
Policy instance 5
Insurance contract or identification number279778
Number of Individuals Covered2999
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $26,375
Total amount of fees paid to insurance companyUSD $20,728
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,205,123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,352
Amount paid for insurance broker fees20728
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number162073
Policy instance 6
Insurance contract or identification number162073
Number of Individuals Covered1581
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $41,615
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $202,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,754
Amount paid for insurance broker fees0
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberR1070B/R1070A
Policy instance 7
Insurance contract or identification numberR1070B/R1070A
Number of Individuals Covered230
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,554,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0292540
Policy instance 8
Insurance contract or identification numberR0292540
Number of Individuals Covered5
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $154
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $1,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $112
Amount paid for insurance broker fees0
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number8837934
Policy instance 2
Insurance contract or identification number8837934
Number of Individuals Covered851
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $77,606
Total amount of fees paid to insurance companyUSD $1,038
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $246,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $72,040
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
UNITED DENTAL CARE OF NEW MEXICO, INC. (National Association of Insurance Commissioners NAIC id number: 47042 )
Policy contract number5481497
Policy instance 13
Insurance contract or identification number5481497
Number of Individuals Covered20
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $40
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees40
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number161670
Policy instance 12
Insurance contract or identification number161670
Number of Individuals Covered826
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $69,617
Total amount of fees paid to insurance companyUSD $-50
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $214,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $69,633
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AXSK
Policy instance 11
Insurance contract or identification numberGLTD0AXSK
Number of Individuals Covered12
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $63
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees63
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AXSK
Policy instance 10
Insurance contract or identification numberGLUG0AXSK
Number of Individuals Covered1798
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $2,038
Total amount of fees paid to insurance companyUSD $2,258
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $42,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,038
Amount paid for insurance broker fees2258
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number13264
Policy instance 1
Insurance contract or identification number13264
Number of Individuals Covered2397
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $104,675
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $278,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number8837934
Policy instance 2
Insurance contract or identification number8837934
Number of Individuals Covered802
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $95,694
Total amount of fees paid to insurance companyUSD $11,158
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $251,767
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 number279778
Policy instance 3
Insurance contract or identification number279778
Number of Individuals Covered3387
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $32,378
Total amount of fees paid to insurance companyUSD $8,546
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,718,276
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 numberR1070B/R1070A
Policy instance 4
Insurance contract or identification numberR1070B/R1070A
Number of Individuals Covered249
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,808,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0292540
Policy instance 5
Insurance contract or identification numberR0292540
Number of Individuals Covered6
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $165
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $1,648
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 numberGLTD0AXSK
Policy instance 6
Insurance contract or identification numberGLTD0AXSK
Number of Individuals Covered10
Insurance policy start date2018-08-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED DENTAL CARE OF NEW MEXICO, INC. (National Association of Insurance Commissioners NAIC id number: 47042 )
Policy contract number5481497
Policy instance 7
Insurance contract or identification number5481497
Number of Individuals Covered23
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 )
Policy contract number5481497
Policy instance 8
Insurance contract or identification number5481497
Number of Individuals Covered23
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,873
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 number230817/603533
Policy instance 10
Insurance contract or identification number230817/603533
Number of Individuals Covered384
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $2,979
Total amount of fees paid to insurance companyUSD $4,664
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $1,574,444
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 number161670/162073
Policy instance 11
Insurance contract or identification number161670/162073
Number of Individuals Covered1421
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $134,453
Total amount of fees paid to insurance companyUSD $1,063
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $434,204
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 numberGLUG0AXSK
Policy instance 9
Insurance contract or identification numberGLUG0AXSK
Number of Individuals Covered1957
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $34,738
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $253,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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