Kaiser Welfare Benefit Plan Annual Report 5500 Form Year 2010

8/3/2019 Kaiser Welfare Benefit Plan Annual Report 5500 Form Year 2010

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Form5500Departmentof (he Treasurylnlernal Revenue Selvice

Depanmento f~abor~mp~oyeeenestsecuniyAdm#nlrtrallon

Annual ReturnlReport of Employee Benefit PlanTI) s form is req-rerl lo bc f rrl for amplcycc ocncil plalls .nuer sccllons 104and 41.65 of [no Empo)cr Rct rerncnt .ncon.eS$!r:..r l y Ar l i,' 1974 (ER.SA) anr!scclions 6.'


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Form 5500 (2010) Page23a Plan administrator's name and address (if same as plan sponsor, enter"Samen)KAISER FOUNDATION HEALTH PLAN. INC.1 KAISER PLAZA, 208OAKLAND. CA 94612

I

3b Administrator's EIN94-1340523

3c Administrator's telephonenumber

570371-5940

4 If the name andlor EiN of the plan sponsor has changed since the last returnlreport filed for this plan, enter the name, EIN andthe plan number from the last returnlreport:a Sponsor's name

I5 Total number of participants at the beginning of the plan year ( 5 1 1217

b Retired or separated participants receiving benefits 6b 1 56........................................................................................................

4b EIN4c PN

6 Number of participants as of the end of the plan year (welfare plans complete only lines 6a, 6b, 6c, and 6d).a nctive participants .......................................................................................................................................................

I6a I 1704I

C Other retired or separated participants entitled to future benefits ............................... ......................................................d Subtotal. Add lines 6a, 6b, and 6c .

6~6d I 1761

Ie Deceased participants whose beneficiaries are receiving or are entitled to receive benefits .................................... .-

g Number of participants with account balances as of the end of the plan year (only defined contribution planscomplete this item)

6e 1If Total. Add lines 6d and 6e ..................................................................................................................................................

I

6f I 1761I

b If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristic Codes in the instructions:4A 48 4D 4E 4F 4H 4L

h Number of participantsthat terminated employment during the plan year with accrued benefits that wereless than 100% vested............................................................................................................................................................. 6h

a Pension Schedules b General SchedulesR (Retirement Plan Information) (1) H (Financial Information)

(2)'I 1 ME (Multiemployer Defined Benefit Plan and Certain Money I (Financial lnformation- Small Plan)Purchase Plan Actuarial Information) -signed by the plan A (Insurance Information)actuary ;:; 1-(4) C (Service Provider Information)(3) 0 B (Single-Employer Defined Benefit Plan Actuarial (5) D (DFEiParticipating Plan Information)Information) - signed by the plan actuary (6) n G (Financial Transaction Schedules)

........Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) 1 7 18a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:

9a Plan funding arrangement (check all that apply)

10 Check all applicable boxes in 10a and l o b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instruciions)

9b Plan benefit rrangement (check all that apply)(1)(2)(3)(4)

InsuranceCode section 412(e)(3) insurance contractsTrustGeneral assets of the sponsor

(1)(2)(3)(4)

X---X---

InsuranceCode section 412(e)(3) insurance contracisTrustGeneral assets of the sponsor


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SCHEDULE A(Form 5500)

lnsurance lnformation I OMBNo. 1210-0110Oepanmenlof the Treasurylnternai~evenueservice

Department of LaborEmployee aenefals securily Admlnisliationpensioneensf81~ u a r a n t y orparation

I

1 Coverage Information:

This schedule is required to be iiied under section 104 of theEmployee Retirement Income Security Act o i 1974 (ERISA).b File a s an attachment to Form 5500.

b Insurance companies are required to provide the informationpursuant lo ERISA section 103(a)(2).

C Plan sponsor's name as shown o n line 2a o i Form 5500.KAISER PERMANENTE MEDICAL CARE PROGRAM

I

(a) Name of insurance carrierKAISER FOUNDATION HEALTH PLAN OF COLORADO

2010This Fo rm i s Open t o Publ icInspect ion

For calendar plan year 2010 or fiscal plan year beginning 0110112010 and ending 1213112010

D Employer ldentiiicatlon Number (EIN)94-6365467

Part I lnformationConcerninglnsuranceContract Coverage, Fees, and CommissionsProvide information io r each contracton a separate Schedule A, Individual contracts grouped as a unit in Parts IIand Il l can be reported on a single Schedule A.

550Name o i planKAISER PERMANENTE WELFARE BENEFIT PLAN

3 Pcrsons r r c r vtog cornmnssonsar.0 'res Complete as many e l~ l r i es s ncrr led lo repon ;i l,ersons)- - - --(a) Name ant1 dodrcus .I Ih c age 11 3r3kcr or Olller kerson 10 chqrll Comm ss Ons o r W - r c r r - p a t d

6 Three-digitplan number (PN) 1

- p~2 Insurance iee and commission information. Enter the total iees and total commissions paid. List in item 3 the agents, brokers. and other persons indescending order o i he amount paid.

(a) Total amount of commissions paid (b) Total amount of iaes paid

(e) Approximate number ofpersons covered at end ofpolicy or contract yearPolicy or contract year

0

I I i(a) Name and address of the agent, broker, or other person to whom com missions or ieas were pald

(d ) Contract orIdentiilcatlon numberb) EI N (f) From

0

(b) Amount o i sales and basecommission^ paid

( c ) NAlCcode (9) TO

For Paperwork Reduct ion Act Not ice and OM6 Control Numbers, see the Instruct ions for Form 5500. Schedule A (Form 5500) 201v.092308.1

(e) Organization codeFees and other comm issions paid

(e )Organization code(b) Amount of sales and basecommissions paid

(c) Amount

I I I

(d ) Purpose

Fees and other commissions paid(c) Amount (d) Purpose


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Schedule A [Form 55001 2010 page 2 - r n(a) Name and address of the aqent, broker, or other person to whom co mmissions or feeswere paid

(a) Name and address of the aqent, broker, or other person to whom co mmissions or fees were paid

(e) Organizationcode(b) Amount of sales and basecommissions paid

-. I(a )h;lvle and ader$!ssc i oe agent, o r l c r or othcr jc rson lo %nulilc o r m sso l : - " r lees 2crc pa o

1 I IFees and other commissions paid


I I I(a) Name and address of the agen t, broker, or other person to whom comm issions or fees were pa id

(c)Amount (d) Purpose

Fees and other commissions paid


(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

(c) Amount (d) Purpose



(c )Amount (d) Purpose

Fees and other comm issions paid

(e) ~rgan iz a t i ocode(b) Amount of sales and basecommissions paid


Fees and other comm issions paid(c )Amount (d) Purpose


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Schedule A (Form 5500) 2010 Page 3

I I this report.4 Current value of plan's interest under this contract in the general accou nt at year end ................................................ 1 4 15 Current value of plan's interest under this contract in separate accoun ts at year end ................................................ 1 5 16 Contracts With Allocated Funds:a State the basis of premium rates b

Part II

b Premium s paid to CarrieC Premium s due but unpaid at the end of the yead If the carrier, service, or other organization incuretention of the contract or policy, enter arnoun

Specify nature of costs b

Investment and Annuity Contract Information\R ?crc nr l l l l l l l i l ronlrac ts a18 PIOVIOC~. tnc cnlrc group ~f ?-l:n no Y 0 3 1 rontrac l? s%fitn ac ll ~ : : l r rCI ma, lie lrcatco as a .n I or ~~~~~~~~~r? 11'

e Type of contract: (1) individual policies(3)0 ther (specify) b (2) group deferred annuity

f I 'rontrnrl l i..rchascd in irholr?or o piln to a slr o.e 3e ne fIs lr2m a term na l ng 3 an cncck ncrr! b n7 conlra


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e Dividends or retroactive rate refunds due. (D o no t include amount entered in c(2).) .........................................10 Nonexperience-rated contracts:

a Total premiums or subscription charges paid to canier .............................................................................. 10a I 8201648

Page 4Schedule A (Form 5500) 2010Part Il l

/ Part IV I Provision of Information11 Di d the insurance company fail to provide an y information necessary to complete Schedule A? ............. Yes No12 If the answer to line 11 is '"Yes: specify the information no t provided. h

Welfare Benefit Contract InformationIf more than one contract covers th e same group of employees of the same employer(s) or members of the same employee organization(s), theinformation ma y be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees,the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report.

b If the carrier, service, or other organization incurred an y specific costs in connection with the acquisition orretention of the contractor policy, other than reported in Part I, item 2 above, report amount............................

8 Benefit an d contract type (check al l applicable boxes)a [ ealth (other than dental or vision) b0 ental c jl vision d Life insurancee 1 emporary disability (accident an d sickness) f 0 ong-term disability g0 upplemental unemployment h Prescription drugi Stop loss (large deductible) j 0 MO contract k PPO contract I Indemnity contractmC] Other (specify) h

(2) Increase (decrease) in amount du e bu t unpaid ......................................(3) lncrease (decrease) in(4) Earned ((1) + (2) (3))

(3) Incurred claims (add (1)and (2))(4) Claims charged

(D) Other expense

(H ) Total retention ...........................................................................................................................................................2) Dividends or retroactive rate refunds. (These amounts were paid in cash, o r 1 credited.)(2) Claim reserve(3) Other reserves

lobSpecify nature of costs h


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SCHEDULE A(Form 5500) 1 lnsurance Information I OM 6 No. 1210-0110oepanment 01 the ireasuryinfernal ~ e v s n u e ervice

Department01LaborEmp l o y e Bsnsflls Security ~dminislalionpenson ~ ~ ~ n l~~~~t~ corporation

I

(a) Name of insurance carrierGROUP HEALTH COOPERATIVE

This schedule is required to be filed under section 104 o i heEmployee Retirement Income Security Act of 1974 (ERISA).b File as an attachment to Form 5500.

b Insurance companies are required to provide the iniormationpursuant to ERISA section 103(a)(2).

C Plan sponsor's name as shown on line 2a of Form 5500.KAISER PERMANENTE MEDICAL CARE PROGRAMi

2010This Form is Open to Public

InspectionFor calendar plan year 2010 or fiscal plan year beginning 0110112010 and ending 1213112010

D Employer Identification Number (EIN)94-6365467Part I Information Concerning lnsurance Contract Coverage, Fees, and Com missions Provide iniorrnation ior each contracton a separate Schedule A. Individual contracts grouped as a unit in Parts Ii and Ill can be reported on a single Schedule A.

I3 Persons receiving commissions and fees. (Complete as many entries a s needed to report ail persons).

(a) Name and address of the agent, broker, or other person to whom commissions or iees were paid

550Name o i planKAISER PERMANENTE WELFARE BENEFIT PLAN

1 Coverage Iniormation:

(b) EIN91-05117702 Insurance fee and commission information. Enter the total iees and total commissions paid. List in item 3 the agents, brokers, and other persons indescending order of the amount paid.

B Three-digitplan number (PN) 1

Policy or contract year

(a) Total amount of commissions paid


(c) NAlCcode95672

( f ) From0110112010

(b) Total amount of fees paid

(b) Amount of sales and basecommission^ paid

(9) TO1213112010

0 1 0

(d) Contract oridentification number0903900

(b) Amount oi sales and basecommissions paid

(e) Approximate number o ipersons covered at end o ipolicy or contract year50

(e) Organization codeFees and other commissions paid

(c) Amount

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Schedule A (Form 5500) 201v.092308

(d) Purpose

(e) Organization codeFees and other commissions paid



8/93

Schedule A (Form 5500) 2010 Page 2 - r n(a) Name and address of the agent, b roker, or other person to whom commissions or fees were paid

(a) Name and address of the age nt, broker, or other person to whom commissions or fees were paid

(b) Amount of sales and basecommissions paid

(b) Amount of sales and base Fees and other commissions paid (e )Organizationcode

(a) Name and address of the agent, broker, or other person to whom comm issions or fees were paid

(e) Organizationcode


(a) Name and address of the agen t, broker, or other person to whom commissions or fees were paid

(c )Amount


(d) Purpose

I I I(a) Name and address of the agen t, broker. or other person to whom com missions or fees were pa id



Fees and other com missions paid(c )Amount


(d) Purpose

(e) OrganizationcodeFees and other com missions paid


(e) OrganizationcodeFees and other comm issions paid



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Schedule A (Form 5500) 2010 Page 3--Investment and Annuity Contract InformationWhere individual contracts are provided, the entire group of such individual contracts with each ca rrier may be treated as a u nlt for purposes ofI ~hs rclion . - . . . .4 Currcnt va "c o; p an s .o!eresr unuer lnls ro o tr ~ u tl l h e gcncral acro..nt at y .. . . .5 Currelotva1.e o; p ao s mtcrcsr undcr lois conlract in sclli lr i l le iccoullts ?I ycar cnc . . . . . .- .- -- - .. - --. -Contracts With Allocated Funds:

a State the basis of premium rates tb Premium s paid to carrieC Premium s due but unpaid at the end of the yead If the carrier, service. or other organ ization incuretention of the contract or policy, enter amoun t

Specify nature of costs te Type of contract: (1 ) individual policies

(3) 0 ther (specify) t (2) 0 roup deferred annuity

f f conIra:! p.rol~ase.l II ivhule or n p a l , o a slr8o.lt oenefits from a term nnln g p a n cncrd hcr r b 3. . - . 7 Conlracts W In Jna ou alr u F-nds !Do no1 nr ..l!e lp0r1'3~1so'lnese ConllacIs main13inei n scparatc nc:.o..ols)a Type of contract: (1) [1deposit administration (2) 0mmediate pallicipation guarantee(3) [7 guaranteed investment (4) 0 ther b

(2) Dividends and credits(3) Interest credited durin(4) Transferred from se parate account ............................................... .( 5 )Other (specify below

e Deductions:(1) Disbursed from fund to pay benefits or purchase annuities during year(2) Administration charge made by ca rrie(3) Transferred to separate account(4) Other (specify below)

(5)Total deductions .........................................................................................................................................f Balance at the end of the current year (sub tract e(5) from d) ............................................................................... 7e(5) I7 f I


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8 Benefit and contract type (check ell applicableboxes)a 1 ealth (other than dental or vision) b Dental C Vision d0 ife insurancee Temporary disability (accidentand sickness) f Long-term disability g Supplemental unemployment h0 rescription drugi 0 top loss (large deductible) j HMO contract k PPO contract I Indemnitycontractm Other (specify) b


9 Experience-ratedcontracts:

Part Ill

a Premiums: (1 ) Amount receive(2) Increase (decrease) n amount due but unpaid ......................................(3) Increase (decrease) n unearned premium reserve ...............................

Welfare Benefit Contract lnformationIf more than one contract covers the same group of employees of the same empioyer(s) or members of the same employee organization(s), heinformation may be combined for reporting purposes if such contracts are experience-ratedas a unit. Where contracts cover individual employees,the entire orouo of such individual contracts with each carrier mav be treated as a unit for ourooses of this reoort.

b Benefit charges ( I ) Claims pai

(A) Commissions

(D)Other expenses

(G) ther retention charge

(2) Dividendsor retro

(2) Claim reserves

b if the carrier, service, or other organization ncurred any specific cosretention of the contract or policy, other than repolled in Part I, tem 2 above, rep


Part IV I Provision of lnformation11 Did the insurance company fail to provide any information necessary to complete Schedule A? ............. Ye s No12 If the answer to line 11 is '"Yes,' specify the information not provided. b


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A Name of planKAISER PERMANENTE WELFARE BENEFIT PLAN

OM6 No. 1210-0110

2010SCHEDULEA

( F o r m 5500 )oepartmentof ths ireasurylniernal~ e v e n u eenice

ospartmen,Of Labor~mployee en efts security ~dministraiion~ e n s l o neriest ~ u a r a n t y orporaton

Insurance InformationThis schedule is required to be filed under section 104 of theEmployee Retirement Income Security Act of 1974 (ERISA).

I File as an attachment to Form 5500.

For calendar plan year 2010 or iiscal plan year beginning 0110112010 and ending 1213112010b Insurance companies are required to provlde the iniormatlon

pursuant to ERISA section 103(a)(2).6 Three-digit

plan number (PN) 1

This Form is Open to PublicInspection

550

C Plan sponsor's name as shown on line 2a of Form 5500.KAISER PERMANENTE MEDICAL CARE PROGRAM


D Employer identification Number (EIN)94-6365467

Part I

(a) Name of Insurance carrlerGROUP HEALTH COOPERATIVE

lnformation Concerning lnsurance Contract Coverage, Fe es, and Comm issions Provide information for each contracton a separate Schedule A. Individual contracts grouped as a unit in Parts II and Ill can be reported on a single Schedule A

3 Persons receiving commissions and fees. (Complete as many entries as needed to reporl all persons).(a) Name and address of the agent. broker. or other person to whom commissions or fees were paid

2 lnsurance fee and commission information. Enter the total fees and total commissions paid. List in item 3 the agents, brokers, and other persons indescending order of the amount paid.

(e ) Approximate number ofpersons covered at end ofpolicy or contract year27

(b) EIN91-0511770



I i I(a) Name and address of the agent, broker, or other person to whom commissionsor fees were paid

(f) From0110112010


(c) NAlCcode95672

(9) To1213112010

0 / 0

(e) Organization code(b) Amount of sales and basecommissions paid

i i IFor Paperwork Reduction Act Notice and OM6 Control Numbers, see the ins tructions for Form 5500. Schedule A (Form 5500) 201v.092308.1

(d ) Contract oridentification number012420


Fees and other commissions paid(c )Amount (d) Purpose

(e)Organization codeFees and other commissions paid



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Schedule A (Form 5500) 2010 Page2 - r n(a ) Name and address of the agent, broker, or other person to whom commissionsor fees were paid


(e ) Organizationcode

(b ) Amount of sales and basecommissions paid

(a ) Name and address of the agent, broker, or other person to wham commissions or fees were paid



(a ) Name and address of the agent, broker, or other person to wham commissions or fees were paid

(c ) Amount (d ) Purpose

(e )OrganizationcodeFees and other commissions paid

(e ) Organizationcode(b)Amount of sales and basecommissions paid

(a ) Name and address of the agent, broker, or other person to whom commissionsor fees were paid

(c ) Amount


(d ) Purpose

Fees and other commissions paid(c )Amount

(b)Amount of sales and basecommissions paid

(d ) Purpose

(e ) OrganizationcodeFees and other commissions paid

(c) Amount (d ) Purpose




13/93


4 Current value o i plan's interest under this contract in the general account at year end .................................................. 1 4 15 Current value o i plan's interest under this contract in separate accounts at year end ............................................... 1 5 1

Part II

6 Contracts With Allocated Funds:a State the basis of premium rates b

Investment and Annuity Contract InformationK x r c no ,ill.al contral: ls are pr,u oe,, tnr r o l re qri,Ji, of such 1~11. J ; ~ C ~ I ~ ~ L . I SJ 18il each r:;lrr cr ma, oc lrraloo as a ..nlI icr p..rl locs i c'

b Premiums paid to CarrieC Premiums due but unpaid If the carrier, service, or

retention of the contractSpecify nature of costs b

e Type o i contract: (1) individual policies(3) 0 ther (specify) b (2) group deferred annuity

f licontract purchased, in whole or in part, to distribute beneiits i rom a terminating plan check here b7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)a Type of contract: (1 ) 0 deposit administration (2) immediate participation guarantee(3) 0 uaranteed investment (4 ) 0 ther b

(2) Dividends and credits

(4) Transferred from separate accoun(5) Other (specify below

e Deductions:(1) Disbursed irom fund to pay benefits or purchase annuities during year(2) Administration charge made by carrier .................................................(3) Transferred to separate account ................................................................(4) Other (specify below) ..............................................................................b

I I(6)Total additions ...................................................................................................................................................d Total of balance and additions (add ba nd ~ ( 6 ) ) ................................................. ......................................7 ~ ( 6 )7d I

...............................................................................................................................................5) Total deductionsf Balance at the end oi he current year (subtract e(5) from d) .............................................................................7e (5 )7f


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I Part IV I Provisionof lnformation11 Did the insurance company fail to provide any information necessary to complete Schedule A? ............. Yes No12 if the answer to line 11 is 'Yes.' specify the information no t provided. 1

Schedule A (Form 5500) 2010 Page 4Part Ill Welfare BenefitContract lnformationIf more than one contract covers the same group of employees of the same employer(s) or members o f the same employee organization(s), theinformation may be combined for repolting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees.the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report8 Benefit an d contract type (check al l applicable boxes)

a [ ealth (other than dental or vision) b[I e n t a l c0 ision d0 ife insurancee Temporary disability (accident an d sickness) f Long-term disability g0 upplemental unemployment h0 rescription drugi 0 top loss (large deductible) j HM O contract k PPO contract I Indemnity contractm [1Other (specify) 1

(2) Increase (decrease) in amount du e bu t unpaid

b Benefit charges (1) Claims pa i

a Total premiums or subscription charges paid to Carrie

Specify nature of costs 1


15/93

~ e n s ~ o nenert ~ u a r a n t y orporaton b Insurance companies are required to provide the information This Form is Open to PublicFor calendar plan year 2010 or fiscal plan year beginning 0110112010 and ending 1213112010


~epartment f t h s ~ r e a s u r yinternal ~wenveserviceoepar,ment of Labor~rnpiayeee n e n t s ecurity~dmins!rai,on

A Name of planKAiSER PERMAWNTEWELFARE BENEFIT PLAN

Insurance InformationThis schedule is required to be fiied under section 104 of theEmployee Retirement Income Security Act of 1974 (ERISA).

1 File as an attachment to Form 5500.

OM5 No. 1210-0110

2010

B Three-digitplan number (PN) )

550

I



I

(a) Name of InsurancecarrrerBLUE CROSSBLUESHIELD OF TEXAS

D Employer Identification Number (EIN)94-6365467

Part I information Concerning In~LIranceContract Coverage, Fees, and Commissions Provide information or each contracton a separate Schedule A. Individual contracts grouped as a unit in Parts II and il l can be reported on a single Schedule A.

3 Persons receiving commissions and fees. (Complete as many entries as needed to report ail persons).(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

FROST INSURANCEAGENCY. INC 5164 VILLAGE CREEK DRIVE, SUITE 200PLANO. TX 75093

(b) EIN

36-12366102 nsurance fee and commission nformation. Enter the total fees and total commissions paid. List in item 3 the agents, brokers, and other persons in

descending order of the amount paid.

(e) Approximate number ofpersons covered at end ofpolicy or contract year

92


I I I(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

(c) NAlCcode70670




60732 1 2316

(e) Organizationcode3

(b) Amount of sales and basecommissions paid60732

For Paperwork Reduction Act Notice and OM6 Contro l Numbers, see the instruct ions for Form 5500. Schedule A (Form 5500) 201v.092308.

(f)From0110112010


(9) To1213112010

Fees and other commissions paid(c) Amount

2316(d) Purpose

SPECIAL PROGRAMBONUS

(e )Organization codeFees and other commissions paid



16/93

Schedule A (Farm 5500) 2010 Page 2 - a(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

(a) Name and address of the agent, broker, or other person to whom commissions or iees were paid



(e )Organizationcode


(e) Organizationcode(b ) Amount o i sales and basecommissions paid

(a ) Name and address of the agent, broker, or other person to whom commissions or fees were paid

(c) Amount


(d) Purpose


(a) Name and address o i he agent, broker, or other person to whom commissions or fees were paid

(c )Amount

(b ) Amount of sales and basecommission^ paid

(d ) Purpose


Fees and other commissions paid(c) Amount

(b )Amount of sales and basecommissions paid

(d) Purpose



Organizationcode

Fees and other commissions paid(c) Amount (d ) Purpose


17/93


1 I this report.4 Current value of plan's interest under this contract in the general accou nt at year end ............................................ 1 4 15 Current value of pian 's interest under this contract in separate accou nts at year end .................................................. 1 5 16 Contracts With Allocated Funds:

a State the basis of premium rates b

Part II

b Premium s paid to carrieC Premiums due but unpaid if the ca rrier, service, orretention of the contract


Investment an d Annuity Contract InformationVlncre nulv uun cunlrarts dra pi .v~ l rd in* r o l re group o i so inr!lv d


18/93

Schedule A (Form 5500) 2010 Page 4Part Il l Welfare ~ e n e f i t z n t r a c tnformationI~ O I C nan onc COnllaCI ~3,crs lht! Samc (Jrl1.p of employees ul l n r somc rrnpc)cr s) or mrmuers of lllt same cmc oycc organ7alo7lsl mt;iriforn.alion may u+ :0111!1 1 1 ~ 3or rccon n ~ j. I P O Y R ~ f i - ~ hs,nlracIs are experieoce-r.jtco a3 a Ln I Wncre :xllllrrl~.IsL.W ' 11 1 . I-al en1plo)ccs.- ~ h cnt rr group os.:h no u t l ~ d ."ntri IS ~ t i nach carrlcr ma, ur 1rc;ilt.d as a "n I or i,.ri,oses oi t) s repon. . . . . . . . . -- ..8 Benefit and contract type (check all applicable boxes)

a 1 ealth (other than dental or vision) b Dental c vision d Life insurancee [1Temporary disability (accident and sickness) f Long-term disability g Supplemental unemployment h Prescriptiondrugi 0 top loss (large deductible) j 0 MO contract k0 PO contract 1 Indemnity contractm 0 ther (specify) b

9 Experience-rated contracts:a Premiums: (1) Amount receive(2) Increase (decrease) in amount due but unpaid............................................3) Increase (decrease) in unearned premium reserve......................

b Benefit charges ( I ) Claims(2) lncrease (decrease) in c - -4) Claims charge - -Remainder of pre

(D) Other expenses

(H ) Total retention..................Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement

(2) Claim reserves

10 Nonexperience-ratedcontracts:a Total premiums or subscription charges paid to carrier ................................................................................ 151930b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition orretention of the contract or policy, other than reported in Part I, item 2 above, report amount. ...........................Specify nature of costs b

Part IV I Provision of lnformation11 Did the insurance company fail to provide any information necessary to complete Schedule A? ............. Yes NO12 If the answer to line 11 is 'Yes,' specify the iniarmation not provided. b


19/93

lnsurance lnformation,~~~~~- - ~ - ,oepanment of the ~ r e a s u ~lnterna ~ e v e n u e e ~ c eoepariment of Lobor

~~~i~~~~ ~ ~ ~ f l t recurity ~ d ~ ~ i ~ t ~ ~ ~ ~ ~ ~enso on ens fit GuarantyCorporalson

This schedule is required to be filed under section 104 of theEmployee Retirement Income Security Act of 1974 (ERISA).b File as an attachment to Form 5500.

I

1 Coverage Information:(a) Name of insurance carrierHUMANA

2010b Insurance companies are requlred to prov~dehe lnformatlon

pursuant to ERISA sectlon 103(a)(2)

C Plan sponsor's name as shown on line 2a of Form 5500.KAISER PERMANENTE MEDICAL CARE PROGRAMi

Thls Form i s Open to Pub l icInspectionFo r calendar plan year2010 or fiscal plan year beglnnlng 0110112010 an d endlng 1213112010

D Employer IdentificationNumber (EIN)94-6365467Part I lnformationConcerning lnsurance Contract Coverage, Fees, and Commissions Provide information for each contracton a separate Schedule A Individual contracts grouped as a unit in Parts II an d IiI can be reported on a single Schedule A.

3 Persons receiving commissions and fees. (Complete as many entries as needed to report all persons).(a) Name an d address of the agent, broker,or other person to whom commissions or fees were paid

55 0Name of planKAISER PERMANENTE WELFARE BENEFIT PLAN

61-1013183

B Three-dlgltplan number (PN) 1

(e) Approximate number ofpersons covered at end ofpolicy or contract year(b) EINPolicy or contract year

(a) Name and address of the agent, broker, or other person to whom comm iss~ons r fees were paid

(f) From

2 insurance fee and commission nformation. Enter the total fees an d total commissions paid. List in item 3 the agents, brokers, an d other persons indescending order of the amount paid.(a) Total amount of commissions paid (b) Total amount of fees paid0 1 0

95885

( c ) NAlCcode (0 To

(e) O rganization code(b) Amount of sales and basecommissions paid

I I IFor Paperwork R eduction Act Notice and OMB Con trol Numbers, see the ins t ruc t ions fo r Form 5500. Schedule A (Form 5500) 20v.092308.

(d) Contract oridentification numberA6820

I IFees and other comm issions paid

(e )Drganlzatlon code(b) Amount of sales and basecommrssrons peld

18

( c )Amount (d) Purpose

Fees and other com mlsslons pald

01/0112010

(c) Amount

12l3112010

(d) Purpose


20/93

Schedule A (Form 5500) 2010 Page 2 - a(a ) Name and address of the agent, broker, or other person to whom commissions or fees were paid

I. .. . .-. - (a ) Nanc ; ~ ~ i l lUUICSS ni t n e ye n l oroker or olncr porson lo nnom ~orhmtsslonsr ' r e ~ar 2 pau (e ) Organizationcode(b ) Amount of saies and basecommissions paid(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

(b ) Amount of saies and basecommissions paid


I I(a) Name and address of the agent. broker, or other person to whom commissions or fees were paid

(c) Amount

I i IFees and other commissions paid

(d ) Purpose

(e) Organization

(e ) Organizationcode(b ) Amount of sales and basecommissions paid

I(a ) Name and address of the agent, broker, or other person to whom commissions or fees were paid

(c ) Amount (d ) Purpose code


(e) Organizationcode(b ) Amount of sales and basecommissions paid

(c) Amount

(b ) Amount of saies and basecommissions paid

(d) Purpose

Fees and other commissions paid(c )Amount (d ) Purpose

(e ) OrganizationcodeFees and other commissions paid



21/93


1 / this report.4 Current value of plan's interest under this contract in the general account at year end ............................................. 1 4 15 Current value of plan's interest under this contract in separate accounts at year end ................................................... 1 5 16 Contracts With Allocated Funds:a State the basis of premium rates b

Part II

b Premiums paid to Carriec Premiums due bul unpad If the carrier, service, or

retention of the contractSpecify nature of costs t

Investment and Annuity Co ntract InformationWhere individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of

e Type of contract: (1) individual policies (2) group deferred annuity(3) 0 ther (specify) h

f If contract purchased. in whole or i n part, to distribute benefits from a terminating plan check here b7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)a Type of contract: (1)0 eposit administration (2 ) immediate participation guarantee

(3) guaranteed investment (4) 0 ther 1

..................................... ............Balance at the and of the previous year ..Additions: (1) Contributions deposited during the year .................................(2) Dividends and credits(3) Interest credited during the year(4) Transferred from s(5) Other (specify be1t

e Deductions: I(1) Disbursed from fund to pay benefits or purchase annuities during year I 7e ( l ) I~-~(6)Total additions ....................................... .....................................................................................................d Total of balance and additions (add ba nd c ( 6 ) ) . .....................................................................................................

(2) Administration charge made by carrier ..................... ..............(3) Transferred to separate account ...........................................................(4) Other (specify below) ......................................................................

7'46)7d

(5) Total deductions ............................................................................................................................................f Balance at the end of the current year (subtract e(5) from d) ...........................................................................

7e(5)7f


22/93

ScheduleA (Form 5500) 2010 Page 4Plrf I l l I Welfare ~ Z c o n t r a c tformat ion. . . . . . . . .If morc lhan c o r ~ : ~ l ~ t r a c lornrs tnc same Jroup of empo)ees o' ne save cnp oyar,~) r rncrnorrs nf !!besauie eniplo,ce orwn zaton(s) tncof.mmton may oc col?~t>ed 'or re~oning ..r,lnces lf iur:h Iontracts nm rxpcr cnct!.rjtc j as a .rial. Wncrc I:


23/93

A Name of planKAISER PERMANENTE WELFARE BENEFIT PLAN


oepaflment of me i reasuw~nternale v e n u e en~cenepanmentor ~ a b a rEmployee Beneilts Secunty Admn#rl ra ton

pension~ e n e r i ~ u a n n h i c o r p o r a f l o n

Fo r calendar plan year 2010 or fiscal plan year beginning 0110112010 and ending 1213112010

Insurance InformationThis schedule is required to b e filed under section 10 4 of theEmployee Retirement Income Security Act of 1974 (ERISA).

b File as a n attachment t o Form 5500.b Insurance companies ar e required to provide the informationpursuant to ERISA section 103(a)(2).

B Three-digitplan number(PN) b

OM 6 No. 1210-0110

2010This Fo rm i s Open to Publ icInspect ion

55 0

C Plan sponsor's name as shown on line 2a of Form 5500.


KAISER PERMANENTE MEDICAL CARE PROGRAMI

(a) Name of insurance carrierDENTAL CARE SERVICES OF HAWAII

94-6365467

Part I lnformationConcerning lnsuranceContract Coverage, Fees, and Commissions Provide information for each contracton a separate Schedule A, Individual contracts grouped as a unit in Parts IIand i ll ca n be reported on a single Schedule A.

3 Parsons rece "(no commtssons an;, i t e s .Compcla e ;- an y ontrlcs as nccocd la rcjlorl il fers3nsI . . .-(a) h a m e an, add res io i tnc agent nro


24/93

ScheduieA (Form 5500) 2010 page 2 - r n(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid



i I I(a ) Name and address of the agent, broker, or other person to whom comm~ssions r fees were pald

(b ) Amount of sales and base Fees and other commissionspaid (e) Organizationcommissions paid (c )Amount (d) Purpose code




(a) Name and address of the agent, broker, or other person to whom commissionsor fees were paid

(c) Amount

(b ) Amount of sales and base Fees and other commissionspaid (e) Organizationcommissions paid (c ) Amount (d) Purpose code

(d) Purpose


I I I( a )Name and address of the agent, broker, or other person to whom commissions or fees were paid

(c ) Amount

(b) Amount of sales and base Fees and other commissionspaid (e )Organizationcommissionspaid (c) Amount (d) Purpose code

(d) Purpose


25/93

ScheduleA (Form 5500) 2010 Page 3

I I this report. .................................................Current value of plan's interest under this contract in the general account at year end 1 4 15 Current value of plan's interest under this contract in separate accounts at year end ................................................. 1 5 16 Contracts With Allocated Funds:a State the basis of premium rates b

Part II

b Premiums paid to carrieC Premiums due but unpad If the carrier, sewice, or

Investment and Annuity Contract InformationWhere individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of

retention of the contract or policy. enter amount............................................................................................Specify nature of costs 1

e Type of contract: (1 ) individual policies (2) group deferred annuity(3) 0 ther (specify) 1

f If contract purchased, n whole or in part, to distribute benefits from a terminating plan check here 1 n7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained n separate accounts)a Type of contract: (1) deposit administration (2) immediate parlicipation guarantee

(3) guaranteed investment (4) other b

..................................(3) Interest credited during the year(4) Transferred from separate acco(5)Other (specify below

(6)Total additionsd Total of balance ae Deductions:

(1) Disbursed from fund to pay benefits or purchase annuities during year(2) Administration charge made by carrie(3) Transferred to separate account(4) Other (specify below)

(5) Total deductions .............................................................................................................................................f Balance at the end of the current year (subtract e(5) from d).............................................................................

7e(5)7f


26/93

-i Stop loss (large deductible) j 0 MO contract k0 PO contract I Indemnity contractm Other (specify) h

ScheduleA (Form 5500) 2010 Page4

a Premiums: (1) Amount received ...........................................................................2) Increase (decrease) n amount due but unpaid..........................

(3) Increase (decrease) n unearned premium reserve ...............................

b Beneiit charges ( 1 ) Claims pai

(4) Claims charge(A) Commissions(6 ) Administrative service or other fees

(D) Other expenses

(G) Other retention charge(H) Total retention

(2) Claim reserves(3) Other reserves

Part Ill

b If the carrier, service, or other organization ncurred any specific costs in connectionwith the acquisition orretention of the contract or policy, other than reported in Part I, item 2 above, report amount............................ lob

Welfare Benefit Contract lnformationIf more than one contract covers the same group of employees oi he same employer(s)or members of the same employee organization(s), heinformationmay be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees.the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report.

Specify nature of costs h

8 Benefit and contract type (check all applicable boxes)a 0 ealth (other than dental or vision) b Dental c vision d0 ife insurancee n Temporary disability (accident and sickness) f u Long-term disability g [1Supplemental unemployment h Prescriptiondrug

I Part IV I Provision of Information11 Did the insurance company fail to provide any information necessary to complete ScheduleA? ............. Yes No12 If the answer to line 11 is '"Yes." specify the information not provided. b


27/93

SCHEDULE A(Form 5500) 1 lnsurance Information I OM6 No. 1210-0110

oepartmentof the ireasunilnternal~ e v e nu e ew~ceDepartment Of Labor~mp io y e e enefltsecvnty~dm~nstraton

pension~ e n e f l t u a r a n i yorporation

I


This schedule is required to be filed under section 104 of theEmployee Retirement IncomeSecurity Act of 1974 (ERISA).

1 File as an attachment to Form 5500.b Insurancecompanies are required to provide the information

pursuant to ERISA section 103(a)(2).

C Plan sponsor's name as shown on llne 2a of Form 5500.KAiSER PERMANENTEMEDICALCARE PROGRAM

i

(a) Name of insurance carrierMETLIFE

2010This Form is Open to PublicInspection

For calendar plan year 2010 or fiscal plan year beginning 0110112010 and ending 1213112010


Part I lnformationConcerning lnsuranceContract Coverage, Fees, and Commissions Provide information for each contracton a separate Schedule A, Individual contracts grouped as a unit in Parts IIand Ill can be reported on a single Schedule A.

550Name of planKAISER PERMANENTEWELFARE BENEFIT PLAN

3 Persons receiving commissions and fees. (Complete as many entrles as needed to report all persons).(a) Name and address of the agent, broker, or other person to whom commissionsor fees were paid

B Three-digitplan number (PN) h

2 lnsurance fee and commission nformation. Enter the total fees and total commissions paid. List in item 3 the agents, brokers, and other persons indescending order of the amount paid.

(a)Total amount of commissions paid (b) Total amount of fees paid

(e) Approximate number ofpersons covered at end ofpollcy or contract year(b) EIN


6463

(a) Name and address of the agent, broker, or other person to whom commlsslonsor fees were paid

(f) From

0


(c) NAlCcode (9) To(d) Contract oridentification number

(b)Amount of sales and basecommlss~ons ald

(e)Organization codeFees and other commissions paid

(c) Amount

For Paperwork ReductionAc t Notice and OM6 Control Numbers, see the instructions for F orm 5500. Schedule A (Form 5500) 20vD92308

(d) Purpose

(e )Organtzat~on odeFees and other commlsslons pa~d

(c )Amount (d ) Purpose


28/93

Schedule A (Form 5500) 2010 page 2 - a(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

. _1 I I. - . . -.. -(alhwr,e ano address u'!hz sgcnt, orodcr, rl r olocr person 10 &l!om comm ss ons or fees nere pa c . ..



I I I(a) Name and address of the agent, broker. or other person to whom commissions or fees were paid




(c) Amount


(d) Purpose

(e) OrganizationcodeFees and other commissions paid

._I_- I. - .--(a) h a m ~nd atlrlrrss-of !he agcn l, ornkrr or olorr l i < ! r i ,n l u $~ l o rnommlsilnns o r fees ~ e r eaio .




( c )Amount


(d) Purpose





29/93

Schedule A (Form 5500) 2010 Page3

I I this report...................................................Current value of plan's interest under this contract in the general account at year end ] 4 15 Current value of plan's interest under this contract in separate accounts at year end ................................................ 1 5 16 Contracts With Allocated Funds:

a State the basis of premium rates 1

Part II

b Premiums paid to u r r ic Premiums due but und If the carrier, service.retention of the contract or policy, enter amoun


Investment and Annuity Contract InformationWnere noiv uu;, rnnlra


30/93

ScheduleA (Form 5500) 2010 Page 4I Part Ill 1 Welfare Benefit Contract lnformation~ -~if morc lhnn one cur>trilui orcr i tllr ;acre 4ro.c of cmpoqees L! ine Sarre tmployerls) ur mcmbcrs of 1 l . t samc so.l,loyee organ zatoms,. lnc~lfurrnalonr3, OP combned 'or rcportlng pl.rprlses f sd:n contrarls ;l-e xper en


31/93

SCHEDULEA(Form 5500)oepanmentof ule reasun/lnlernal ~ e v e n u e ewlceOBpanmBnt Of Labor~mpioyee eneflts ecvnly ~dmtnisiraton

pension ~eneflt u a r a n t y orporalion

I


Insurance InformationThis schedule is required to be filed under section 10 4 of theEmployee Retirement Income Security Act of 1974 (ERISA).

b File as an attachment t o Fo rm 5500.b Insurance companies are required to provide the informationpursuant to ERISA section 103(a)(2).

C Plan sponsor's name as shown on line 2a of Form 5500KAISER PERMANENTE MEDICAL CARE PROGRAMI

(a) Name of Insurance carrlerKAISER FOUNDATION HEALTH P L A O F MIPATLANTIC STATES

OM 5 No. 1210-0110

2010This Form is Open t o Publ icInspect ion

Fo r calendar plan year 2010 or fiscal plan year beginning 0110112010 an d ending 1213112010

D Employer Identification Number (EIN)94-6365467Part I lnformation Concerning lnsurance Contract Coverage, Fees, and Commissions Provide information for each contracton a separate Schedule A, Individual contracts grouped as a unit in Pal ls II and IIica n be repolled on a single Schedule A.

2 lnsurance fee an d commission information, Enter the total fees and total commissions paid. List in item 3 the agents, brokers, an d other persons indescending order of the amount paid.(a) Total amount of commissions paid (b) Total amount of fees paid0 I 0

550Name of planKAISER PERMANENTE WELFARE BENEFIT PLAN

3 P ~ ~ ~ U I I Se & v ~ g ~ ~ n i r nv'ons :lo3 fees ~ C nm v ~ i es many en1r.c~ s ncooco 10 r c u o ~ll ;~ersolis). -(a ) Namc anr! :ruuress o ' l nc a q m l . oruker o r ot l l t r [person I o E l o r n commlssons or f r r s r%erc a 0

B Three-digitplan number (PN) b

(e ) Approximate number ofpersons covered at en d ofpollcy or contract yearPolicy or contract year

I I I(a ) Name and address of the agen t, broker, or other person to whom commlsslons or fees were pald

(d) Contract oridentification numberb) EI N (fJ rom

(b) Amount of sales and basecommlsslons paid

(c) NAlCcode (9) TO

I I IFor Paperwork Red uct~ on ct Not ice and OMB Cont ro l Numbers, see the instructions for Form 5500. Schedule A (Form 5500) 20v.092308

(e )Organlzatlon codeFees and other comm~ ss~on satd

(e) Organ~zat~onod e(b) Amount of sales and basecomm lsslons paad

(c)Amount (d) Purpose

Fees and other commlssions pald(c) Amou nt (d) Purpose


32/93

Schedule A (Form 5500) 2010 page 2 - D(a ) Name and address oi he agent, broker, or other person to whom commissions or fees were paid

I I i(a) Name and address oi he agent, broker, or other person to whom commissions or fees were pald


I i I(a ) Name and address of the agent, broker, or other person to whom commissionsor fees were paid



(e) Organizationb) Amount oi sales and base


(c )Amount


(b) Amount of sales and base Fees and other commissionspaid (e) Organizationcommissions paid (c )Amount (d) Purpose codeI

(d) Purpose

commissions paid

(e) Organizationcode(b) Amount of saies and basecommissionspaid


(b) Amount o i sales and base Fees and other commissionspaid (e) Organizationcommissions paid (c ) Amount (d) Purpose code

(c )Amount

Fees and other commissionspaid(c )Amount

(d) Purpose

(d) Purpose

code


33/93


b Premium s paid to carrieC Premiums due but unpad If the carrier, service, or other organization incurred any spe cific costs in conne ction with the acquisition orretention of the contract or policy, enter amoun t


Part II

e Type of contract: (1) individual policies(3) 0 ther (specify) 1

Investment and Annuity Contract InformationWhere individual contracts are provided, the entire group of such individual con tracts with each ca rrier may be treated as a u nit for purposes ofthis report.

(2) group deferred annuity

......................... ................Current value of p lan's interest under this contract in the general account at year en d .. 1 4 15 Current value of p lan's interest under this contract in separate accou nts at year end ..................................................... 1 5 16 Contracts With Allocated Funds:

a State the basis of prem ium rates 1

f If contract purchased, in whole or in part, to distribute ben efits from a term inating plan check here 1 07 Contracts With Una llocated Funds (Do not include portions of these contracts maintained in separate accounts)a Type of contract: (1) deposit administration (2) immed iate participation guarantee

(3) 0 uaranteed investment (4) 0 ther 1

(2) Dividends and credits(3) Interest credited during the yea(4) Transferred from se parate acc(5) Other (specify below


(1) Disbursed from fund to pay be nefits or purchase annuities during year(2) Administration charge made by carrie(3) Transferred to separate account ..............................................................(4) Other (specify below)

.................................................................................................................................................5) Total deductionsf Balance at the end of the current year (subtract e(5) from d) ................................................................................

7e(5)7f


34/93

--e n Temporary disability (accident an d sickness) f Long-term disability gn Supplemental unemployment h Prescription drug


-i [7 Stop loss (large deductible) -j 0 MO contract k PP O contract I 0 ndemnity contractm Other (specify) b

Part Ill

(3) Increase (decrease) in unearned premium reserve ...............................b Benefit charges ( I ) Claims pa i

(B ) Administrative service or other fee(D) Other expense

(G ) Other retention charges(H)Total retention

(2 ) Claim reserve


Welfare Benefit Contract lnformationIf more than on e contract covers the same group of employees of the same employer(s) or members o f the same employee organization(s), theinformation may be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees,the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report.

I Part IV I Provision of lnformation11 Did the insurance company fail to provide an y information necessary to complete Schedule A? ............. Yes No12 If the answer to line 11 is "Yes,' specify the information no t provided. b

8 Benefit an d contract type (check al l applicable boxes)a fl Health (other than dental or vision) b Dental cn vision d Life insurance


35/93

Department of LabarEmpoyeeBeneflts Security Admnisfraion b File as an attachment t o Form 5500.

OM B NO. 1210.0110

2010SCHEDULEA(Form 5500)

~epartment r theTreasuryinternal evenu us serv~ce

~ s n r , o nenent ~ u a r a n t yarporatlon I b Insurance companies are required to provide the information I his ~ o r ms Ooen to Public

Insurance InformationThis schedule is required to be flled under section 104 oftheEmolovee Retirement income Securitv Act o i 1974 (ERISA).

pursuant to ERISA section 103(a)(2). Inspection



D Employer identiiication Number (EIN)94-6365467

I

(a) Name o i nsurance carrierGROUP HEALTH COOPERATIVE

For calendar plan year2010 or fiscal plan year beginning 01/01/20i0 and ending 12/31/2010

Part I Information Concerning lnsurance Contract Coverage, Fees, and CommissionsProv rlr nforln4t.o for each conlr:ll:l


- on a vrporale Scnee. c A n3','aua conlral.ls gru-pea as a 1 1 Pans 11 do11 11 ca? or?rrpurle2 gn a s ngle SLIIEO-e A

3 Persons receiving commissions and fees (Complete as many entries as needed to report ail persons).(a) Name and address of the agent, broker, or other person to whom commissions or iees were paid


91-0511770I

(e) Approximate number o ipersons covered at end of

policy or contract year(b) EINPolicy or contract year

I I I(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

(0From

2 Insurance fee and commission iniormation. Enter the total iees and total commissions paid. List in item 3 the agents, brokers, and other persons indescending order of the amount paid.

(a) Total amount of commissions paid (b) Total amount o i ees paid0 1 0

95672

(c ) NAlCcode (9) To

(e )Organization code(b) Amount of sales and basecommissions paid

I i IFor Paperwork Reduction Act Nottce and OM6 Control Numbers, see the instructions for For m 5500. Schedule A [Form 5500) 20v.092308

(d) Contract oridentification number

0927000


(e) Organ~zatlan ode(b) Amount of sales and basecommiss~ons ald

79

( c )Amount (d) Purpose

Fees and other commlsslons pa ~ d

01/01/2010

(c ) Amount

12/31/2010

(d ) Purpose


36/93

Schedule A (Form 5500) 2010 Page 2 - m(a) Name and add ress of the agent, broker, or other person to whom commissions or fees were paid

(a) Name and address of the agent, broker, or other person to whom commissions or fees were p ald

(b) Amount of saies and basecommissions paid

I I I(a) Name and address of the agent. broke r, or other person to whom commissions or fees were paid


Fees and other com missions paid

(e)Organizationcode(b) Amount of saies and basecommissions paid

i I I(a) Name an d address of the agent, broker, or other person to whom comm~ssions r fees were paid

(c) Amount

I I I

(b) Amount of sales an d basecommissions paid

(d) Purpose

Fees and other comm issions paid


(c ) Amount

(b) Amount o i sales an d basecommissions paid

(d) Purpose

(e) OrganizationcodeFees an d other commissions paid



(e )Organizationcode(b) Amount of saies and basecommissions paid


Fees an d other commissions paid(c) Amount (d) Purpose


37/93

Schedule A (Form 5500) 2010 Page 3-Current value of plan's interest und erthis contract in the general account at year end .................................................. 1 4 15 Current value of p lan's interest under this contract in separate acco unts at year end ................................................. 1 5 16 Contracts With Allocated Funds:a State the basis of premium rates b

Part II Investment and Annuity Contract InformationWhere individua l contracts are provided. the entire group of suc h individual contracts with each c arrier may be treated as a unit for purposes of

d I' lh c car llcr. sCIVI:e C . other organ z.lto o IIIL-rrc-0 any spe:.': cosls n connccton :)In lhc a1:l 11sIllillLTletenton of !he coolr i lc l ur cc ~ c f -nlcr amn..nl . . . . . . . . . . . . . . . . . . . . . .

b Premium s paid to carrier .....................................................................................................................................C Premiums due but unpaid at the end of the year .................................................................................................

Specily nature of costs b

6b I6~ I

e Type of contract: (1) individual policies(3) 0 ther (specify) b


f If contract purchased, in whole or in pa rt. to distribute benefits irom a terminating plan check here b 07 Contracts With Una llocated Funds (Do not include portions of these contracts maintained in separate accounts)a Type of contract: (1) deposit administration (2) immed iate participation guarantee

(3) guaranteed investment (4) other b

.................................(2) Dividends and credit(3) Interest credited duri(5) Other (spec iiy below


(1) Disbursed from fund to pay benefits or purchase annuities during year(2) Administration charge made by carrier(3 ) Transierred to separate account ................................................................(4) Other (specify belo

I I(5) Total deductions ...............................................................................................................................................f Balance at the end of the current year (subtract e(5) from d) ..............................................................................

7e(5) Ii I


38/93

I Part IV I Provision of lnformation - -


11 Did the insurance company fail to provide any information necessary to complete ScheduleA? ............. I I Ye s I I No12 l i the answer to line 11 is "Yes;' specify the iniorrnation not provided. )

Part Il l Welfare Benefit Contract lnformationIf more than one contract covers the same group of employees of the same employer(s) or members of the same employee organization(s). heinformation may be combined for reporting purposes if such contracts are experience-ratedas a unit. Where contracts cover individualemployees.the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report.8 Benefit and contract type (check all applicable boxes)

a 1 ealth (other than dental or vision) b Dental c vision d Life insurancee 0 emporary disability (accidentand sickness) f Long-term disability g0 upplemental unemployment h1 rescription drugi Stop loss (large deductible) j HMO contract k PPO contract I 0 ndemnitycontractm0 ther (specify) b

(3) Increase (decrease) in(4) Earned ((1) + (2) - (3))

(B) Administrativeservice or other(C) Other specific acquisition cost

(H) Total retentio

b If the carrier, service, or other organization incurred any speciSc costs in connection with the acquisitionorretention of the contract or policy,other than reported in Part I, tem 2 above, report amount ...........................Specify nature of costs b


39/93

SCHEDULEA(Form 5500)

~epar i rnent f the ~ t e a s u winternal ~ e v e n u e e~v,csDeparimenlof ~ a b o r~mployseenefits securty ~dm,nistral ion

~ e n s ~ o nenssk ~ u a ~ a n t yorporaton

I


Insurance InformationThis schedule is required to be filed under section 104 of theEmployee Retirement income Security Act of 1974 (ERISA).

b File as an attachment to Form 5500.b Insurance companies are required to provide the information



I

(a) Name of insurance carrlerHAWAII DENTAL SERViCE

OM6 No. 1210-0110

2010This Form is Open to Public

InspectionFor calendar plan year 2010 or fiscal plan year beginning 0110112010 and ending 1213112010


Part I

t iontrac~ r persons covered at end ofI . code I identification number I ' '.._,]cy or contract year / (f) Fromlnformation Concerning lnsurance Contract Coverage, Fees, and Commissions Provide information for each contracton a separate Schedule A. Individual contracts grouped as a unit in Parts IIand Ill can be reported on a single Schedule A.


3 Persons receiving commissions and fees. (Complete as many entries as needed to report all persons).

B Three-digitplan number (PN) h

2 Insurance fee and commission information. Enter the total fees and total commissions paid. List in item 3 the agents, brokers, and other persons indescending order of the amount paid.

RICHARE I KERSTEN 458 AULIMA LOOPKAILUA. HI 96734

(a) Total amount of commissions paid (b) Total amount of fees paid


fe) Organization code(b) Amount of sales and basecommissions paid

For Paperwork Reduction Act Notice and OM6 Control Numbers, see the instructions f or Fo rm 5500. Schedule A (Form 5500) 20v.092308


(e) Organ~zation ode(b) Amount of sales and basecommissions paid


Fees and other commlsslons paid(c) Amount (d) Purpose


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Schedule A (Form 5500) 2010 Page 2 - n(a) Name and address of the agent, broker. or other person to whom commissionsor fees were paid

(a) Name and address of the agent. broker, or other person to whom commissionsor fees were paid


I. --. . . . ... .-. hame an


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1 this report.4 Current value of plan's interest under this contract in the general account at year end............................................... 1 4 15 Current value of plan's interest under this contract in separate accounts at year end ............................................. .....I 5 16 Contracts With Allocated Funds:a State the basis of premium rates b

Part II

b Premiums paid to carrierC Premiums due but unpaid If the carrier, service, or other organization ncu

retention of the contract or policy, enter amounSpecify nature of costs b

Investment and Annuity Contract InformationWhere individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of

e Type of contract: (1) 1 ndividual policies(3) fl other (speciiy) b

(2) 0 roup deferred annuityf If contract purchased, in whole or in part. to distribute benefits from a terminating plan check here b 1

7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained n separate accounts)a Type of contract: (1) fl deposit administration (2) 0 mmediate participation guarantee(3) 0 uaranteed investment (4) 1 ther b

(2) Dividends and credit(3) Interest credited during(4) Transferred from separate account(5) Other (specify below)b

(6)Total additiond Total of balance and additions (add ba nd c(6)). .............................................................e Deductions:

(1) Disbursed from fund to pay benefits or purchase annuities during year I 7e(l) II- -......................................................2) Administration charge made by carrier(3 ) Transferred to separate account ...............................................................(4) Other (specify below) ...............................................................................

(5) Total deductions ............................................................................................................................................f Balance at the end of the current year (subtract e (5 ) from d) ............................................................................ 7e(5)7f


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ScheduleA (Form5500) 2010 Page 4

e Temporary disability (accident and sickness) f 0 ong-term disability g Supplementalunemployment h Prescriptiondrugi 0 top loss (large deductible) j 0 MOcontract k PPOcontract I Indemnitycontractm Other (specify) b

Part Ill

9 Experience-ratedcontracts:a Premiums: (1) Amount received

(4 ) Earned((I)(2) - (3))b Benefit charges ( I ) Claims paid

(2) Increase (decrease) in claim(4 ) Claims charge

(6 )Administrativeservice or other fees

(G)Other retention charges


Welfare Benefit Contract lnformationIf more than one contract covers the same group of employees of the same employer(s)or membersof the same employeeorganization(s), theinformationmay be combined for reporting purposes if such contracts are experience-ratedas a unit. Where contracts cover individual employees,the entire group of such individual contractswith each carrier may be treated as a unit for purposes of this report.

I Part IV I Provision of lnformation11 Did the insurance company fail to provide any information necessary to complete ScheduleA? ............. Yes NO12 If the answer to line 11 is 'Yes: specify the information not provided. b

8 Benefit and contract type (check all applicable boxes)a 0 ealth (other than dental or vision) b5 en t a l c vision d Life insurance


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SCHEDULE A(Form 5500) 1 lnsurance Information I OM 0 No. 1210-0110

KAISER PERMANENTE MEDICAL CARE PROGRAM 94-6365467

~ e p a i t m e n tf the ~ r e a s ur ylntsrnal ~ s v e ~ ~ eewiceoepanmenlof ~ a b o r~mployes enefits Secvnty ~dminrlration

pension ~ s n e f l t uannty Corporaton


This schedule is required to be filed under section 104 of theEmployee Retirement IncomeSecurity Act oi 1974 (ERISA).

b File as an attachmentto Form 5500.b Insurance companies are required to provide the information


I

(a) Name of insurance carrierSAFEGUARD HEALTH PLAN. INC

2010This Form is Open to PublicInspection

For calendar plan year 2010 or fiscal plan year beginning 01~0112010 and ending 12/31/2010

Part I InformationConcerning lnsurance Contract Coverage, Fees, and Commissions Provide information for each contracton a separate Schedule A, Individual contracts grouped as a unit in Palls II and Ill can be reported on a single Schedule A.

550Name of planKAISER PERMANENT WELFAREBENEFIT PLAN

I3 Persons receiving commissionsand fees. (Complete as many entries as needed to report all persons)

(a) Name and address of the agent, broker, or other person to whom commisslons or fees were pald


(b ) EIN

2 Insurancefee and commission information. Enter the total fees and total commissions paid. List in item 3 the agents, brokers, and other persons indescending order of the amount paid.




(c ) NAlCcode (0 From

(b ) Total amount of fees paid

(b ) Amount of sales and basecommission^ paid

(9) To

0 1 0

(d) Contract oridentification number

(b ) Amount of sales and basemmrnlsslons pald

(e) Approximate number ofpersons covered at end ofpolicy or contract year

(e )Organization codeFees and other commissions paid

(c) Amount

For Paperwork Reduction Act Notwe and OM6 Control Numbers, see the instructions for Form 5500. Schedule A [Form 5500) 20v.092308

(d) Purpose

(e) Organlzabon codeFees and other commiss~ons ad

( 6 )Amount (d)Purpose


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Schedule A (Form 5500) 2010 page 2 - D(a) Name and address oi he agent, broker, or other person to whom commissions or iees were paid


(e )Organizationcode(b) Amount of sales and basecommissions paid

I i I(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid


(e) Organizationcode(b ) Amount oi sales and basecommissions paid

I I I(a ) Name and address of the agent, broker, or other person to whom commissions or iees were paid

(c )Amount


(d) Purpose


i I(a) Name and address of the agent, broker, or other person to whom commissions or iees were paid

(c )Amount (d ) Purpose



(e) Organizationcode(b) mount o i sales and basecommissions paid



(e) Organizationcode(b ) Amount of sales and basecommissions paid

(c )Amount Id ) Purpose



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.I I this report. ..............................................Current value of plan's interest under this contract in the general account at year en d 4 15 Current value of plan's interest under this contract in separate accounts at year end ..................................................... 1 5 1Part II

6 Contracts With Allocated Funds:a State the basis of premium rates b

Investment and Annuity Contract InformationWhere individua l contracts are provided, the entire qroup o i such individual contracts with each c arrier may be treated as a unit for purposes o i

b Premium s paid to carrieC Premiums due but unpad If the carrier, service, orretention oit he contract or policy, enter amoun

Specify nature of costs )

e Type of contract: (1) [1 ndividual policies(3) 0 ther (specify) b


f If contract purchased, in whole or in part, to distribute benefits iro m a terminating plan c heck here b 07 Contracts With U nallocated Funds (Do not include portions of these co ntracts maintained in separate accounts)a Type of contract: (1) deposit administration (2) immed iate participation guarantee

(3) [1guaranteed investment (4) 0 other b

(2) Dividends and credits(3) Interest credited during the yea r(4) Transierred from separate acco ...........................................................(5) Other (specify below

(6)Total additionsd Total of balanc e a ...............................................................e Deductions:(1) Disbursed from fund to pay ben eiits or purchase annuities during year(2)Administration charge mad e by carrie(3) Transferred to separate account(4) Other (specify below)

(5)Total deductions ..................................................................................................................................................f Balance at the end of the current year (sub tract e(5) from d) ................................................................................

7e ( 5 )7f


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Schedule A (Form 5500) 2010 Page4

I I the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report.Part Ill

8 Benefit and contract type (check all applicable boxes)a Health (other than dental or vision) b1 ental C0 ision d Llfe insurancee 0 emporary disability (accident and sickness) f Long-term disability g0 Supplemental unemployment h Prescription drugi Stop loss (large deductible) j 1 MO contract k0 PPO contract I Indemnity contractm Other (specify) b

Welfare Benefit Contract lnformationIf more than one contract covers the same group of employees of the same employer(s) or members of the same employee organization(s), theinformation may be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees,

9 Experience-ratedcontracts:a Premiums: ( I ) Amount received

(2) increase (decrease) in amount due but unpaid ......................................(3) Increase (decrease) in unearned premium reserve...........................(4) Earned ( ( I ) + (2) - (3))b Benefit charges ( I ) Claims paid(2) Increase (decrease) in claim ....................................................(3) Incurred claims (add (1) and (2)

(8) Administrative service or other fees(D) OUler expense

., ..................................................F) Charges for risks or other contingencies..........................................................G) Other retention charges Sc(l)(G) I(H )Total retention ........................................................................................................................................(2) Dividends or retroactive rate refunds. (These amounts were[Ipaid in cash, o r 0 credited.) ....................

d Status of policyholder reserves at end of year: (1) Amount held to provide benefits afler retirement ...............(3) Other reserve

10 Nonexperlence-rated contracts:a Total premiums or subscription charges paid to carrier ....................................................................................... 124069b If the carrier, service, or other organization incurred any specific costs in conneclion with the acquisition orretention of the contract or policy, other than reported in Part I, item 2 above, report amount. ...........................Specify nature of costs b

I Part IV I Provision of lnformation11 Did the insurance company fail to provide any information necessary to complete Schedule A? ............. Ye s No1 2 If the answer to line 11 is '"Yes: specify the information not provided. b


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OMB No . 1210-0110SCHEDULE A(Form 5500)~ ~ ~ ~ f l m e n tithe ~reasurylnleina Revenue Serrlce

oepamsn t of Labor~mpioyee ene f i ts ecur~ly dm n ~ s t r r t o n

Insurance InformationThls schedule IS requlred to be 61ed under sectlon 104 of theEmployee Retirement Income Secunty Act of 1974 (ERISA)

1 Fife as an attachment to Form 5500.pension ~enei~t~uarantyorporabon

Part I lnformation Concerning lnsurance Contract Coverage, Fees, and Commissions v rovos nioro-at on lor earn a ln l r ~ : too a separate Sche3uleA indlv rlu:$ c.~~lraclsg r o ~ p c a s n c.?t1 n Pans i l no IIcan 02 rcnnneu oil a sinyc Scncdllie A .-

I


b insurance companies are required to provide the informationpursuant to ERISA section 103(a)(2).

C Plan sponsots name as shown on line 2a of Form 5500.KAiSER PERMANENTE MEDICAL CARE PROGRAM

(a) Name of insurance carrierDELTA DENTAL PLAN OF CALIFORNIA

This Fo rm is Open t o Publ icInspect ionFo r calendar plan year2010 or fiscal plan year beginning 0110112010 an d ending 1213112010


2 lnsurance fee an d commission information. Enter the total fees an d total commissions paid. List in item 3 the agents, brokers, an d other persons indescending order of the amount paid.(a) Total amount of commissions paid [b ) Total amount of fees paid0 1 0

55 0Name of planKAISER PERMANENTE WELFARE BENEFIT PLAN

3 Persons receiving commissions and fees. (Complete as many entries as needed to reporl all persons).(a) Name an d address of the agent, broker, or other person to whom commissions or fees were paid

6 Three-digitplan number (PN) 1

(e) Approximate number ofpersons covered at en d ofpolicy or contract year89368

(b ) EI N94-1461312

Pollcy or contract year

I I I[a) Name and add ress of the agent, broker, or other person to whom commissions or fees were paid

(f) From0110112010

( c ) NAlCcode81396

(9) To1213112010

(e) Organ~z at~onode(b) Amount of sales and basecommissions pa d


Fees and other commissions pald

(e )Organbzatron code(b) Amount of sales and basecomm~ ss~ onsald

(c )Amount

For Paperwork Reduct ion Act Notice andOMB Control Numbers, se e the instruct io ns for For m 5500. Schedule A (Form 5500) 201v.092308.

(d) Purpose

Fees and oUler commissions p a ~ d(c) mount (d)Purpose


48/93

Schedule A (Form 5500) 2010 Page 2 - r n(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid


(b) Amount of sales and base Fees and other commissrons paid (e)Organizationcomm~ss~onsaid code



I , I(a) Name and address of the agent, broker, or other person to whom commissionsor fees were paid



( c )Amount

(b) Amount of sales and base Fees and other commissions paid (e) Organizationcode

(d) Purpose


(a) Name and address of the a g

Fees and other commissionspaid(c )Amount


(d ) Purpose

I I I(e) Organizationcode

Fees and other commissionspaid(c) Amount (d) Purpose


49/93


I . .I this report.4 Current value of plan's interest under this contract in the general a ccount at year end ............................................... 1 4 15 Current value of plan's interest under this contract in separate accounts at year end ................................................... 1 5 16 Contracts With Allocated Funds:Part II

a State the basis of prem ium rates )

Investment and Annuity Contract InformationWhere individual contracts are provided, the entire group of such individua l contracts with each ca rrier may be treated as a u nit for purposes of

b Premium s paid to carrieC Premiums due but und If the carrier, service,retention of the contract or policy, enter amoun

Specify nature of costs be Type of contract: (1 ) individual policies (2) 0 roup deferred annuity

(3) 0 ther (specify) hf If contract purchased , in whole or in part, to distribute benefits from a terminating p lan check here h

7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate acco unts)a Type of contract: (1) n deposit

Kaiser Welfare Benefit Plan Annual Report 5500 Form Year 2010

Documents

Transcript of Kaiser Welfare Benefit Plan Annual Report 5500 Form Year 2010