UNGER FABRIK, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan UNGER FABRIK, LLC HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2018: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-06-01 | 153 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-06-01 | 105 |
| Number of retired or separated participants receiving benefits | 2018-06-01 | 10 |
| Number of other retired or separated participants entitled to future benefits | 2018-06-01 | 0 |
| Total of all active and inactive participants | 2018-06-01 | 115 |
| Number of employers contributing to the scheme | 2018-06-01 | 0 |
| 2017: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-06-01 | 313 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 208 |
| Number of retired or separated participants receiving benefits | 2017-06-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2017-06-01 | 5 |
| Total of all active and inactive participants | 2017-06-01 | 222 |
| Number of employers contributing to the scheme | 2017-06-01 | 0 |
| 2016: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-06-01 | 388 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 301 |
| Number of retired or separated participants receiving benefits | 2016-06-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2016-06-01 | 8 |
| Total of all active and inactive participants | 2016-06-01 | 315 |
| 2015: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-01 | 340 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 424 |
| Number of retired or separated participants receiving benefits | 2015-06-01 | 13 |
| Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 4 |
| Total of all active and inactive participants | 2015-06-01 | 441 |
| 2014: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-06-01 | 400 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-06-01 | 350 |
| Number of retired or separated participants receiving benefits | 2014-06-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2014-06-01 | 0 |
| Total of all active and inactive participants | 2014-06-01 | 354 |
| 2013: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-01 | 374 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 409 |
| Number of retired or separated participants receiving benefits | 2013-06-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 11 |
| Total of all active and inactive participants | 2013-06-01 | 426 |
| 2012: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-06-01 | 308 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 338 |
| Number of retired or separated participants receiving benefits | 2012-06-01 | 12 |
| Number of other retired or separated participants entitled to future benefits | 2012-06-01 | 9 |
| Total of all active and inactive participants | 2012-06-01 | 359 |
| 2011: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-06-01 | 171 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-06-01 | 142 |
| Number of retired or separated participants receiving benefits | 2011-06-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2011-06-01 | 6 |
| Total of all active and inactive participants | 2011-06-01 | 154 |
| 2010: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-06-01 | 124 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-06-01 | 120 |
| Number of retired or separated participants receiving benefits | 2010-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2010-06-01 | 3 |
| Total of all active and inactive participants | 2010-06-01 | 125 |
| 2009: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-06-01 | 94 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-06-01 | 119 |
| Number of retired or separated participants receiving benefits | 2009-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2009-06-01 | 0 |
| Total of all active and inactive participants | 2009-06-01 | 121 |
| 2007: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-06-01 | 204 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-06-01 | 161 |
| Number of retired or separated participants receiving benefits | 2007-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2007-06-01 | 193 |
| Total of all active and inactive participants | 2007-06-01 | 355 |
| 2006: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2006 401k membership |
|---|
| Total participants, beginning-of-year | 2006-06-01 | 187 |
| Total number of active participants reported on line 7a of the Form 5500 | 2006-06-01 | 192 |
| Number of retired or separated participants receiving benefits | 2006-06-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2006-06-01 | 65 |
| Total of all active and inactive participants | 2006-06-01 | 264 |
| 2018: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-06-01 | Type of plan entity | Multi-employer plan |
| 2018-06-01 | Plan funding arrangement – Insurance | Yes |
| 2018-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-06-01 | Type of plan entity | Multi-employer plan |
| 2017-06-01 | Plan funding arrangement – Insurance | Yes |
| 2017-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-06-01 | Type of plan entity | Multi-employer plan |
| 2016-06-01 | Submission has been amended | No |
| 2016-06-01 | This submission is the final filing | No |
| 2016-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-06-01 | Plan is a collectively bargained plan | No |
| 2016-06-01 | Plan funding arrangement – Insurance | Yes |
| 2016-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-06-01 | Type of plan entity | Multi-employer plan |
| 2015-06-01 | Submission has been amended | No |
| 2015-06-01 | This submission is the final filing | No |
| 2015-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-06-01 | Plan is a collectively bargained plan | No |
| 2015-06-01 | Plan funding arrangement – Insurance | Yes |
| 2015-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-06-01 | Type of plan entity | Multi-employer plan |
| 2014-06-01 | Submission has been amended | Yes |
| 2014-06-01 | This submission is the final filing | No |
| 2014-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-06-01 | Plan is a collectively bargained plan | No |
| 2014-06-01 | Plan funding arrangement – Insurance | Yes |
| 2014-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-06-01 | Type of plan entity | Multi-employer plan |
| 2013-06-01 | Submission has been amended | No |
| 2013-06-01 | This submission is the final filing | No |
| 2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-06-01 | Plan is a collectively bargained plan | No |
| 2013-06-01 | Plan funding arrangement – Insurance | Yes |
| 2013-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-06-01 | Type of plan entity | Multi-employer plan |
| 2012-06-01 | Submission has been amended | No |
| 2012-06-01 | This submission is the final filing | No |
| 2012-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-06-01 | Plan is a collectively bargained plan | No |
| 2012-06-01 | Plan funding arrangement – Insurance | Yes |
| 2012-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-06-01 | Type of plan entity | Multi-employer plan |
| 2011-06-01 | Submission has been amended | No |
| 2011-06-01 | This submission is the final filing | No |
| 2011-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-06-01 | Plan is a collectively bargained plan | No |
| 2011-06-01 | Plan funding arrangement – Insurance | Yes |
| 2011-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2010 form 5500 responses |
|---|
| 2010-06-01 | Type of plan entity | Multi-employer plan |
| 2010-06-01 | Submission has been amended | No |
| 2010-06-01 | This submission is the final filing | No |
| 2010-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-06-01 | Plan is a collectively bargained plan | No |
| 2010-06-01 | Plan funding arrangement – Insurance | Yes |
| 2010-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-06-01 | Type of plan entity | Multi-employer plan |
| 2009-06-01 | Submission has been amended | No |
| 2009-06-01 | This submission is the final filing | No |
| 2009-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-06-01 | Plan is a collectively bargained plan | No |
| 2009-06-01 | Plan funding arrangement – Insurance | Yes |
| 2009-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2007: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2007 form 5500 responses |
|---|
| 2007-06-01 | Type of plan entity | Single employer plan |
| 2007-06-01 | Submission has been amended | No |
| 2007-06-01 | This submission is the final filing | No |
| 2007-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-06-01 | Plan is a collectively bargained plan | No |
| 2007-06-01 | Plan funding arrangement – Insurance | Yes |
| 2007-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2007-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2007-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2006: UNGER FABRIK, LLC HEALTH AND WELFARE PLAN 2006 form 5500 responses |
|---|
| 2006-06-01 | Type of plan entity | Single employer plan |
| 2006-06-01 | Submission has been amended | No |
| 2006-06-01 | This submission is the final filing | No |
| 2006-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2006-06-01 | Plan is a collectively bargained plan | No |
| 2006-06-01 | Plan funding arrangement – Insurance | Yes |
| 2006-06-01 | Plan benefit arrangement – Insurance | Yes |
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 47803 |
| Policy instance | 3 |
| Insurance contract or identification number | 47803 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $381 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $1,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $161 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 4 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 277226 |
| Policy instance | 2 |
| Insurance contract or identification number | 277226 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $49,593 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $877,403 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,825 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 230414 |
| Policy instance | 1 |
| Insurance contract or identification number | 230414 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $23,358 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $483,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,358 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 230414 |
| Policy instance | 1 |
| Insurance contract or identification number | 230414 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $26,841 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $671,614 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,841 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 277226 |
| Policy instance | 2 |
| Insurance contract or identification number | 277226 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $64,051 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $1,287,308 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64,051 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, INC. |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 47803 |
| Policy instance | 3 |
| Insurance contract or identification number | 47803 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,728 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $3,416 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $930 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 4 | | Insurance broker name | SANDRA ALLEN |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | JCE39 |
| Policy instance | 4 |
| Insurance contract or identification number | JCE39 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $972 | | Total amount of fees paid to insurance company | USD $98 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $6,002 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $449 | | Amount paid for insurance broker fees | 35 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | G COOKE |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | JCE39 |
| Policy instance | 3 |
| Insurance contract or identification number | JCE39 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $13,305 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CANCER, HOSPITAL | | 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 $31,282 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,079 | | Insurance broker organization code? | 3 | | Insurance broker name | MICHAEL FISHMAN |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 277226 |
| Policy instance | 2 |
| Insurance contract or identification number | 277226 | | Number of Individuals Covered | 491 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $91,630 | | Total amount of fees paid to insurance company | USD $368 | | 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 | 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 $2,073,269 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $85,393 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 368 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 230414 |
| Policy instance | 1 |
| Insurance contract or identification number | 230414 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $40,029 | | 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 $835,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,607 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 230414 |
| Policy instance | 2 |
| Insurance contract or identification number | 230414 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $31,335 | | 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 $625,778 | | 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 | 277226 |
| Policy instance | 1 |
| Insurance contract or identification number | 277226 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $69,290 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,385,220 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9787060 |
| Policy instance | 5 |
| Insurance contract or identification number | 9787060 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $2,531 | | 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 | 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 $25,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,290 | | Insurance broker organization code? | 3 | | Insurance broker name | HIGHRIDGE INSURANCE SERVICES LLC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5467229 |
| Policy instance | 4 |
| Insurance contract or identification number | 5467229 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $21,051 | | Total amount of fees paid to insurance company | USD $11,556 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $210,295 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,946 | | Amount paid for insurance broker fees | 11556 | | Additional information about fees paid to insurance broker | PRODUCER BONUS PROGRAM PAYMENT NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HIGHRIDGE INSURANCE SERVICES LLC |
|
| UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 ) |
| Policy contract number | 5467229 |
| Policy instance | 3 |
| Insurance contract or identification number | 5467229 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $2,367 | | Total amount of fees paid to insurance company | USD $1,294 | | 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 $23,630 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,956 | | Amount paid for insurance broker fees | 1294 | | Additional information about fees paid to insurance broker | PRODUCER BONUS PROGRAM PAYMENT NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HIGHRIDGE INSURANCE SERVICES LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 230414 |
| Policy instance | 1 |
| Insurance contract or identification number | 230414 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $31,335 | | 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 $625,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,091 | | Insurance broker organization code? | 3 | | Insurance broker name | HIGHRIDGE INSURANCE SERVICES LLC |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 277226 |
| Policy instance | 2 |
| Insurance contract or identification number | 277226 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $69,290 | | 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 | 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 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 $1,385,220 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $57,855 | | Insurance broker organization code? | 3 | | Insurance broker name | HIGHRIDGE INSURANCE SERVICES LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9787060 |
| Policy instance | 6 |
| Insurance contract or identification number | 9787060 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $946 | | 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 | 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 $10,622 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5467229 |
| Policy instance | 5 |
| Insurance contract or identification number | 5467229 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $20,893 | | Total amount of fees paid to insurance company | USD $11,411 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EE, SPOUSE, CHILD VOL AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 30/5467347 |
| Policy instance | 4 |
| Insurance contract or identification number | 30/5467347 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $551 | | Total amount of fees paid to insurance company | USD $301 | | 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 | VOL STD, VOL TEMPORARY DISABILITY | | 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 $5,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 34/5467346 |
| Policy instance | 3 |
| Insurance contract or identification number | 34/5467346 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $1,974 | | Total amount of fees paid to insurance company | USD $1,137 | | 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 $19,739 | | 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: 00000 ) |
| Policy contract number | 230414 |
| Policy instance | 1 |
| Insurance contract or identification number | 230414 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $31,440 | | 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 $576,781 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,440 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 277226 |
| Policy instance | 2 |
| Insurance contract or identification number | 277226 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $55,393 | | Total amount of fees paid to insurance company | USD $786 | | 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 | 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 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 $1,078,712 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $55,393 | | Amount paid for insurance broker fees | 786 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9787060 |
| Policy instance | 4 |
| Insurance contract or identification number | 9787060 | | Number of Individuals Covered | 373 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $2,290 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,279 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,290 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5467229 |
| Policy instance | 5 |
| Insurance contract or identification number | 5467229 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $21,004 | | Total amount of fees paid to insurance company | USD $3,636 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $210,037 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,004 | | Amount paid for insurance broker fees | 3636 | | Additional information about fees paid to insurance broker | FEES AND OTHER COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 ) |
| Policy contract number | 5467229 |
| Policy instance | 3 |
| Insurance contract or identification number | 5467229 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $2,553 | | Total amount of fees paid to insurance company | USD $362 | | 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 $25,526 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,553 | | Amount paid for insurance broker fees | 362 | | Additional information about fees paid to insurance broker | FEES AND OTHER COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 277226 |
| Policy instance | 2 |
| Insurance contract or identification number | 277226 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $44,174 | | 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 | 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 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 $985,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,174 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 ) |
| Policy contract number | 1D021944 |
| Policy instance | 3 |
| Insurance contract or identification number | 1D021944 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $20,215 | | Total amount of fees paid to insurance company | USD $1,768 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $182,865 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,215 | | Amount paid for insurance broker fees | 1768 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9787060 |
| Policy instance | 4 |
| Insurance contract or identification number | 9787060 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $2,322 | | 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 | 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 $23,212 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,322 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 230414 |
| Policy instance | 1 |
| Insurance contract or identification number | 230414 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $27,134 | | Total amount of fees paid to insurance company | USD $85 | | 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 $561,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,134 | | Amount paid for insurance broker fees | 85 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 230414 |
| Policy instance | 1 |
| Insurance contract or identification number | 230414 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $16,197 | | 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 $346,417 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | L6747A/C,NHLIFE |
| Policy instance | 2 |
| Insurance contract or identification number | L6747A/C,NHLIFE | | Number of Individuals Covered | 155 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $36,298 | | 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 | 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 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 $760,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 ) |
| Policy contract number | 021944 |
| Policy instance | 3 |
| Insurance contract or identification number | 021944 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $14,944 | | Total amount of fees paid to insurance company | USD $656 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $130,793 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9787060 |
| Policy instance | 4 |
| Insurance contract or identification number | 9787060 | | Number of Individuals Covered | 285 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $1,927 | | 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 | 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 $18,785 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | US405601 |
| Policy instance | 1 |
| Insurance contract or identification number | US405601 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $25,979 | | 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 $520,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 ) |
| Policy contract number | 805215 |
| Policy instance | 2 |
| Insurance contract or identification number | 805215 | | Number of Individuals Covered | 231 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $8,986 | | 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 | 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 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 $180,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 892015 ET AL |
| Policy instance | 4 |
| Insurance contract or identification number | 892015 ET AL | | Number of Individuals Covered | 312 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $10,294 | | 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 $102,953 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9787060 |
| Policy instance | 5 |
| Insurance contract or identification number | 9787060 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $895 | | 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 | 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 $8,971 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 ) |
| Policy contract number | 40000100011658 |
| Policy instance | 6 |
| Insurance contract or identification number | 40000100011658 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $5,499 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $36,659 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 230414 |
| Policy instance | 3 |
| Insurance contract or identification number | 230414 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $8,619 | | Total amount of fees paid to insurance company | USD $14 | | 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 $176,467 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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